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DISEASES OF THK SKIN 



PRACTICAL TREATISE 



ON 



DISEASES OF THE SKIN 






BY 



LOUIS A. DTTHRWG, M.D., 

PROFKSSOR OF DISEASES OK THE SKIN IN THB HOSPITAL 01 Till'. 1NIVF.RSITY "1 

PENNSYLVANIA J PHYSICIAN TO THB DISPENSARY FOR SKIN DISEASES, 

PHILADELPHIA; AUTHOR OF "ATLAS OF SKIN DISEASES"] KTC. 







PHILADELPHIA 

J. B. LIPPINCOTT & CO. 

1877 






Copyright, 1877, by Locis A. Duhiung, M.D. 



TO 

FERDINAND HEBRA, 

PROFESSOR OF DERMATOLOGY IN THE UNIVERSITY 01 vii.wa. A I STRIA, 

WHOSE RENOWN AS A KEEN AND ACCURATE OBSERVER, AN UNRIVALLED 

TEACHER, AND AN EM1NKXTI.Y BKILFUL PHYSICIAN, [S AS 

CORDIALLY RECOGNIZED ON THIS CONTINENT 

AS IN EUROPE, 

$ltte Wwk te dedicated, 

WITH SENTIMENTS OF PROFOUND REGARD AND ADMIRATION, 

BY HIS FORMER PUPIL, 

THE AUTHOR. 



PREFACE. 



In preparing this volume it has been my aim to write 
a concise, practical and useful treatise, one which, while 
making no pretensions to being exhaustive, should com- 
prise sufficient to afford a clear insight into the elements 
of Dermatology and a knowledge of all the important tacts 
in connection with each disease treated of. The primary 
object being to render the subject simple and intelligible, 
and to free it from unnecessary encumbrances, it has been 
deemed best to avoid scrupulously all questions of theory, 
discussion of unsettled points, and the introduction of use- 
less or obsolete terms. Consideration of these and kindred 
topics, however interesting, would have carried the volume 
beyond the limits assigned to it. Xor, for the same reason, 
has any attempt been made to enter into the literature of 
Dermatology ; for information of this character I may refer 
the reader to the comprehensive and sterling work of Hebra 
and Kaposi, the translation of which is now in course of 
publication by the Xew Sydenham Society, of London. 
The subject-matter, indeed, has everywhere been rigor- 
ously condensed, in many instances, I am well aware, at 
the sacrifice of smoothness and elegance of diction. 

The nomenclature employed is essentially that now in 
common use by the prominent writers and teachers of our 
own country and of Europe. 

vii 



vili PREFACE. 

Xh( ification of Hebra, with certain changes and 

modifications, has, after long and careful study, been adopted 
from the conviction that when rightly comprehended it af- 
fords the most satisfactory and practically useful method of 
grouping cutaneous diseases with which we are familiar. 

QSlderable attention has been bestowed upon the defi- 
nition- of the various diseases. They have for the most 
part beeo made from a clinical stand-point, with a view to 
their being of practical value, and consist mainly of succinct 
descriptions of the characteristic lesions and symptoms. In 
several instances, however, the subject appeared either so 
complex or so obscure that it was thought advisable not to 
attempt its definition. 

I can but incidentally refer to the fact that disorders of 
the skin manifest more or less variation in type as they 
occur in one or in another part of the world. Having had 
-nine few years ago favorable opportunities for observing a 
large number of cutaneous affections in the various countries 
of Europe, and since then of studying these diseases in the 
United States, I can state that in many instances they differ 
materially in type as they are seen on the two continents. 
Without entering into this interesting subject, it may be 
remarked that the diseases met with here resemble more 
closely those of Great Britain than those of either France 
or Germany. A recognition of this fact must, I think, go 
far in accounting for the discrepancies which exist in the 
riptions of certain diseases as given by trustworthy ob- 
servers. 

I desire to make special acknowledgment of the assist- 
ance derived from the writings of Hebra, Kaposi, Neumann, 
Wilson, Fox, and Andersou, a list of whose works, as well 
as the works of other writers to whom occasional reference 
has been made, may be found at the close of the book. 



PREFACE. IX 

In the sections devoted, to treatment I have endeavored 
to make mention briefly of all those methods favorably 
regarded by dermatologists at large, but in particular to 
bring forward those remedies and modes of treatment which 
have proved of greatest benefit in my own experience. 

The illustrations of the structure of the normal skin and 
of the parasites are the work of my friend and co-worker 
Dr. Arthur Van Harlingen, to whom I cordially acknowl- 
edge my indebtedness not only for the admirable original 
drawings, but also for many favors tendered during the 
preparation of this volume. My thanks are also due to 
Mr. J. McCreery, proof-reader, for acceptable suggestions 
made during the progress of the sheets through the press. 

The illustrations have been reproduced by the Photo- 
Engraving Company of New York. 



L. A. D. 



Philadelphia, 1416 Spruce St., 
December, 1876. 



CONTENTS. 



PART I. 
GENERAL CONSIDERATIONS 



Anatomy of the Skin 

Symptomatology 

Etiology . 

Pathology 

Diagnosis 

Treatment 

Prognosis 

Classification 



PAGE 

17 
40 
55 

-•> 

80 
96 



PART II. 
SPECIAL DISEASES. 

CIL^SS I. 

ANOMALI.E SECRETIONIS— DISORDERS OF SECRETION. 

Seborrhceu ............ 102 

Comedo . . . . . . . . . . . . .110 

Milium 119 

Molluscum Sebaceum .......... 121 

Sebaceous Cyst 124 

Hyperidrosis . . . . . . . . . . . .125 

Bromidrosis 129 



XII 



CONTENTS. 



i oidrosif 

Anidr. 



CLASS II. 
JI V 1' I •: It. KM I. E— HYPEREMIAS. 



Erythema Bimplez , 
ema Intertrigo 



CLASS III. 
EXSUDATIONES— EXUDATIONS. 



Erythema Multiforme 
Erythema Nodosum . 
Urticaria . 
Eczema 

a Febrilis 

- Zoster . 
Herpes Iris 
Miliaria . 
Pemphigus 
Lichen Planus . 
Prurigo 

Lichen Scrofulosus . 

Acne 

Acne Rosacea . 

- Non-Parasitica 
Impetigo . 
Impetigo Contagiosa 
Ecthyma . 

. 

Pityriasis Rubra 

Furunculus 

Hydradenitis 
Aleppo Bouton 
Delhi Boil 
Biskra Bouton 



141 
144 
146 
156 
216 
220 
227 
230 
237 
246 
250 
256 
257 
269 
277 
281 
285 
288 
291 
311 
314 
317 
317 
317 
317 





CONTENTS. 


Xlll 

PAGE 


nthrax .... 




. 318 


Poisoned Wounds . 




. 321 


Dissection "Wounds 




. 322 


Pustula Maligna . 




. 322 


Equinia . 
ermatitis 




. 323 
. 323 



CLASS TV. 
HEMORRHAGIC—HEMORRHAGES. 



Purpura . 

Hsematidrosis 



330 
335 



CLASS ■V. 
HYPERTROPHI.E— HYPERTROPHIES. 



Lentigo 

Chloasma . 

Naevus Pigmentosus . 

Callositas . 

Clavus 

Cornu Cutaneum 

Verruca . 

Papilloma Cutis 
Ichthyosis 
Lichen Pilaris . 
Scleroderma 
Sclerema Neonatorum 
Elephantiasis Arabum 
Dermatolysis 
Hypertrophy of the Hair 
Hypertrophy of the Nail 



336 
338 
342 

343 
345 
347 
349 
353 
353 
359 
361 
365 
367 
371 
373 
376 



CLASS -VI. 
ATROPHIC— ATROPHIES. 



Albinism 
Vitiligo 



380 
381 



XIV 



CONTEXTS. 



• 
Atrophia < lutii . 

• Macula Atrophica 
Aforphoaa .... 

Atrophy . 
Alopecia . 

cia Areata 
Atrophy of the Hair 
Atrophy of the Nail 



CLASS VII. 
NEOPLASMATA-NEW GKOWTHS. 



Keloid 

Molluscum Fibrosuin 
Xanthoma 
Bhinoscloroma . 

Lupus Erythematosus 
Lupus Vulgaris 
Scrofuloderma . 
Elephantiasis Grascorum 

Framboesia 

Pellagra . 
Syphiloderma . 
Epithelioma 
Sarcoma Cutis . 

- Vasculosis . 
Telangiectasis . 
Lymphangioma Cutis 
Lymphadenoma Cutis 
Neuroma Cutis. 



Hyperesthesia 
Dermatalgia 

Pruritus . 

:iesia 



CLASS VIII. 
NEUKOSES— NEUKOSES. 



CONTENTS. 



XV 



CH^SS IX. 
PARASITE— PARASITES. 



Tinea Favosa . 
Tinea Circinata 
Tinea Tonsurans 
Tinea Sycosis . 
Tinea Versicolor 
Scabies 

Leptus . 

Pulex Penetrans . 

Filaria Medinensis 

(Estrus . 

Demodex Folliculorum 
Phtheiriasis 

Cimex Lectularius . 

Pulex Irritans 

Culex 

Ixodes 



PAGB 

528 
537 
544 
553 
561 
570 
583 
584 
584 
585 
585 
587 
508 
599 
600 
600 



DISEASES OF THE SKIN 



FA.RT I. 

GENERAL CONSIDERATIONS. 



ANATOMY OF THE SKIN. . 

The skin is a covering which invests the body completely, 
giving it form and also protecting it. It is a flexible mem- 
brane, and possesses both elasticity and extensibility. Upon 
its surface are numerous lines or markings, of various size 
and form, which are particularly well defined about the 
hands and feet. Larger and coarser furrows occur about 
the joints, and on the face. Numerous minute depressions 
also exist upon the surface, the orifices of glandular ducts 
and of hair follicles. Hairs, either fine or coarse, are found 
upon almost all regions of the body; they are more highly 
developed in certain parts than in others. 

To the touch the skin has a soft, smooth, somewhat unc- 
tuous feel. In color it varies exceedingly; it is encountered 
possessing all degrees of shade from whitish-pink to black, 
according to the race. In thickness it likewise varies, de- 
pending upon locality; it is thickest on the back, buttocks, 
palms and soles, and thinnest on the eyelids. 

It is to be considered as an organ of touch, by means 
of which we obtain a knowledge of the objects with which 
we come in contact. It is extremely sensitive, and by it we 
are enabled to distinguish between heat and cold, hardness 

2 17 



Is ANATOMY OF THE SKIN. 

and softness, and other opposite qualities and degrees of 
difference. This sensibility is found to vary in different 
parts of the body; it is most acute upon the ends of the 
fingers. 

It is moreover endowed with the power of absorption. 
Substances in a state of solution readily enter the system 
through this avenue; solid substances, as, for example, mer- 
cury, are likewise taken up by the system, but with more 
difficulty. It has been proved by numerous experiments 
that the horny layer of the epidermis acts as a decided 
impediment to this process.* 

The skin secretes both sebaceous matter and sweat, which 
serve to give it softness and suppleness. Certain regions give 
out these secretions in greater abundance than others; the 
scalp, for instance, is well provided with sebaceous glands, 
and the axillae with sweat glands. 

The function of perspiration is a most important one, and 
plays a conspicuous part in the economy; when it occurs in 
an imperceptible manner it is termed insensible, when in ex- 
cess sensible. The amount of this secretion normally poured 
out in the course of twenty-four hours, in the case of an 
adult, has been estimated by Lavoisier and Seguin and others 
at about two pounds. 

Certain gases, as carbonic acid, and other substances, are 
eliminated from the body through the sudoriparous glands. 

The skin, viewed anatomically, is a complex organization. 
It consists of parts, some of which are essential and every- 
where present, while others exist only in certain regions. Of 
the former we have the epidermis, the corium, and the sub- 
cutaneous connective tissue; of the latter, which are termed 
idages, there are sebaceous glands, sweat glands, hairs, 
and nails. In addition to the parts already mentioned, the 
skin contains bloodvessels, lymphatics, aud nerves. 

In order to obtain a thorough comprehension of the sub- 



*See Auspitz, Ueber die Kesorption ungeloster Stoffe bei Saugethieren. 
^ tener Med. Jahrb., 1871. Abstract by the author, Phil. Med. Times, vol. 
i. No. 24. Also, Neumann, Ueber die Aufnahme des Quecksilbers durch die 
unverletzte Haut. AVien. Med.^Vochenschrift, 1871. 



ANATOMY OF THE SKIN. 



19 



ject it will be necessary to consider these various structures 
separately. 

EPIDERMIS. 

The epidermis or cuticle is a membrane composed entirely 
of cells, which covers the corium in all its parts, adapting 
itself closely to the various elevations and depressions of 
this structure. It is made up of two distinct strata, termed 
the horny and mucous layers, which appear separated by a 
denned line. 



A ■-:- 



B '*$M^ 



mm III 






V3M. 



m^s 









*8 &j&'^--C£- 




;w 



*8fts 




- I 



Fig. I. — Section of Normal Skix. A, Horny layer of the epidermis. B, Mucous layer of 
the epidermis. C, Corium, with papillae. D, Tactile corpuscle. E, Sebaceous gland. F, Hair. 
G, Erector-of-the hair muscle. H, Sweat glani. I, Pacinian corpuscle. J, Subcutaneous con- 
nective tissue. 

Horny layer — Stratum corneum. — This is the external or 
superficial layer, and constitutes the greater part of the epi- 
dermis. It consists of a great number of cells, uniform in 
structure, and so closely packed together in the form of 
strata, one upon the other, as to give it the appearance of a 



A5AT0MT OF THE SKIN. 

solid mass. Detached from the skin and viewed as a whole, 
eeu to be a whitish, opaque membrane, varying in thick- 
and density according to the locality from which it has 
been removed. Its intimate structure can be determined only 
l,v isolating the constituent elements, when it will be found 
insist o\' numerous, firmly adherent, flat, polygonal cells 
or plates. In the deepest layer these cells bear a close resem- 
blance to those of the mucous layer; they are, however, 
Hatter and less granular, and are not acted upon by car- 
mine. They are, for the most part, without nuclei. In 
the more superficial layers they become flatter and more 
polygonal, and upon the surface they exist as wrinkled, 
crumpled scales or horn-like plates. They measure about 
-.V" (.0256 mm.). 

Mucous layer — Stratum mucosum — Eete mucosum — Rete 
Malpighii. — This is situated beneath the horny layer, and in 
direct contact with the corium. It is a soft, gelatinous, deli- 
cate, newly formed membrane, in most localities much thinner 
than the horny layer, and is composed of cells with large and 
distinct nuclei. The form, structure, and arrangement of 
these cells differ in the various strata. In the deepest layer, 
touching the corium, they consist of a somewhat granular 
mass, columnar in form, without cell membrane, and contain 
an oval nucleus. 

The cells of the next few layers are larger, homogeneous, 
polygonal, with one or more rounded nuclei, and have a 
distinct membrane giving off tooth-like processes or prickles, 
which fit into oue another. These are termed jwickle or rib 
cells. As the surface of the mucous layer is approached, the 
cells tend to assume a flatter shape and the nuclei to become 
smaller. Like those of the horny layer, they are very ad- 
herent. They may be separated by chemical reagents, and 
by like means the whole mucous layer may be isolated from 
the corium. 

The epidermis varies greatly in thickness; it is thinnest 
about the lips and other parts of the face, and thickest upon 
the palms and soles. It measures from-^'" (.0284 mm.) to 
V" (2.136 mm.) or more. 



ANATOMY OF THE SKIN. 21 

Its surface presents a series of furrows or linear markings. 
Two kinds may be distinguished: a larger and deeper variety, 
occurring in connection with the joints and flexures of the 
bod}', and a smaller, more superficial variety, traversing the 
whole surface in various directions, and dependent upon the 
arrangement of the papillae of the corium. The latter are 
to be seen upon all regions of the skin, in the form of a 
mosaic pattern, intersecting and forming small, polygonal 
spaces. Both perform a service in the movements of the 
body and of the skin itself. They have been made the 
subject of careful study by C. Langer.* 



BB 



«. 






Pig. II. — Epidermis and Papillary Layer. A, Horny layer of the epidermis. B, Mucous 
layer of the epidermis. C, Prickle-cells of the mucous layer. I>, Papilla of the corium contain- 
ing a tactile corpuscle. E, Papilla coutaiuiug a bloodvessel. F, Papilla with a lymphatic vessel. 

CORIUM. 

The corium, called also derma, cutis, and true skin, is the 

* Sitzungs-Berichte der Kais. Acad. d. TYiss. AVien, 1861, Bd. xliv., xlv. 
See Swerchcsky, Am. Jour, of Syph. and Derm., July, 1871. 



ANATOMY OF THE SKIN. 

important structure of the integument. It is a firm 
membrane, made up for the most part of connective tissue, 
therwith clastic fibres, and contains bloodvessels, nerves, 
lymphatics, smooth muscles, hairs, glands, and fat cells. It 
is divided into two portions, an upper and a lower, termed 
respectively the papillary and reticular layers. 

Papillary layer— Pars papillaris.— So called from its peculiar 
p >rmation. It consists of a dense tissue, with certain minute 
finger-like prolongations or prominences, which are desig- 
nated papilla. These bodies vary both in size and in shape, 
according to the region in which they exist. They are small, 
nipple-like elevations, quite solid in structure, with an irregu- 
larly conical or club-shaped form. They are either single, 
or are associated together by a common base; in the latter 
event they receive the name of compound papilla. In size 
they vary greatly. They measure, upon an average, about 
T V" (.0712 mm.). They are found most perfectly developed 
upon the inner surfaces of the fingers and toes, where they 
assume the shape of elongated, conical bodies, with circular 
bases. Upon the face they are shorter, and consist of blunt, 
wart-like prominences. Their arrangement likewise varies. 
They are, however, for the most part, arranged either in 
straight lines or in the form of a semicircle. Upon the tips 
of the fingers they are seated side by side in striae, two or 
more rows of them being included within one of the external 
lines of the epidermis visible to the naked eye. They are 
present in greatest number about the palm, sole, and matrix 
of the nail. Meissner* counted upon the end of the finger 
four hundred to one square line of surface (2.136 mm.). 

Papilla? may be divided into two kinds, according to their 
internal structure, vascular and nervous or sensory. The former 
are well supplied with bloodvessels, while the latter are made 
up in great part of a peculiar tissue containing nerve elements, 
and possess but a limited amount of vascularity. 

Reticular layer — Pars reticularis. — The papillary layer 



* Beitrage zur Anat. und Phys. der Haut. Leipzig, 1853. 



I merges into the reticular layer without distinct line of de- 
marcation, the difference between these strata consisting in 
the arrangement of the connective-tissue fibres. 

The reticular portion is looser in texture than the papillary 
layer, and is made up of fasciculi of connective tissue, which 
decussate and give it a plexiform appearance. As these 
bands of tissue ascend towards the surface, they are observed 
to divide and to continue dividing into smaller and finer 
bundles until they reach the papillary structure, where only 
a few of the fibres are seen to interlace. It forms the bulk 
of the corium. 

The thickness of the corium varies in different regions. 
Kolliker* estimates it to average from \" f (.2670 mm.) to 
\\ ,n (3.204 mm.); in most localities it will be found to 
measure about \ ,n (.5340 mm.). It is thickest upon the 
soles, palms, buttocks, and back, and thinnest upon the 
eyelids, prepuce, and labia majora. 

The corium is bounded above by the mucous layer of the 
epidermis, and below by the subcutaneous connective tissue, 
into which it insensibly passes. 

SUBCUTANEOUS CONNECTIVE TISSUE. 

This portion of the integument is made up of bundles of 
ordinary connective tissue, which cross one another and form 
a coarse network. Compared with the corium it is a loose 
structure, and contains usually an abundance of fat. This is 
found to exist in large quantity about the mammary glands, 
palms, and soles. In some regions, however, the subcuta- 
neous connective tissue is without fat, as about the ears 
and eyelids. Where the fat lobules are found in number, 
the layer receives the name of adipose tissue or panniculus acli- 
posus. The collections or lobules of fat consist of rounded 
or oval fat cells closely packed together and enclosed in a 
network. According to Biesiadecki,f the fat cells possess 
a very thin membrane, containing a minute drop of oil 

* Manual of Human Microscopic Anatomy. London, 1860, p. 76. 
f Strieker's Human and Comparative Histology. London, 1872, vol. ii. 
p. 219. 



_- 1 ANATOMY OF THE SKIN. 

which keeps the membrane bo tightly stretched that it is 
Bcarcelj discernible during life. The fat may, however, be 
extracted with ether, when the thin membrane will be seen, 
with a round nucleus. Each fat lobule is supplied with a fine 
plexus of bloodvessels, and each cell is further surrounded 
b delicate capillary vessel. Quite large bloodvessels 
through the subcutaneous connective tissue, giving off 
branches to the coriura and the structures contained within 
ir. Pacinian corpuscles and lymphatic vessels are also found 

here. 

Above it blends intimately with the corium, while its 
deeper layers are connected with the superficial fascia of 
muscles. The presence or absence of fat in this layer of the 
skin determines to some extent the external form of the body. 

BLOODVESSELS. 

The corium is an exceedingly vascular tissue having 
numerous bloodvessels throughout its structures, existing 
in the form of trunks and capillaries. The main vessels 
snd from the subcutaneous connective tissue, and give off 
branches laterally in all directions, supplying the glands and 
hair follicles as well as the corium itself. Towards the papil- 
lary layer a delicate and highly-organized plexus of capil- 
laries exists, affording an abundant supply to this region. 
The papillae receive capillary loops, which run through their 
centre, or at their sides, parallel to their long axes. The 
papillae containing developed nervous structure are supplied 
with very fine capillary loops.* 

LYMPHATICS. 

The skin is abundantly supplied with lymphatic vessels. 
Neumannf has demonstrated them in the papillae, in the 
lower layers of the corium, in the subcutaneous and adipose 
tissues, and in connection with the hair follicles and seba- 

* See Thin, Jour, of Anat. and Phys., vol. viii., 1874, p. 37. 

f Zur Kenntniss der Lymphgefasse der Haut des Menschen und der 
Sfiugethiere. Wien, 1873. Abstract by the author, Phila. Med. Times, 
vol. iii. No. 43. 



«r ■ 

ceous and sweat glands. According to this observer, they 
present an enclosed tubular system, with independent walls, 
whose interior is lined with flat epithelium. These walls 
are nowhere interrupted by openings; no communication, 
therefore, existing with the so-called lymph spaces. The 
anatomy of these spaces, termed also juice canals, is as yet 
unsatisfactorily determined.* 

The results of the investigations of both Biesiadecki and 
Neumann show that there exists some specific relation be- 
tween the bloodvessels and lymphatics of the skin ; they 
are found for the most part accompanying each other. Large 
lymphatics, however, are often discovered independent of 
bloodvessels. 

The lymphatics in the corium form two close and separate 
networks, the deeper being much the more extensive of the 
two. Valves have been demonstrated in the walls of the 
larger lymphatic vessels of the subcutaneous connective 
tissue ; they have not, however, been seen in the smaller 
vessels. 

The hair follicles, sebaceous and sweat glands each possess 
their own system of lymphatic capillaries. Lymphatic ves- 
sels exist in greatest number about the scrotum, prepuce, 
and labia majora. 

NEKVES. 

On account of the difficulty of demonstrating nerve struc- 
tures, our knowledge in this direction has until quite re* 
cently been limited. Both medullated and non-medullated 
nerve fibres are known to exist in the skin ; the former ter- 
minate, as a rule, in peculiar bodies, called the corpuscles 
of Pacini and Tactile corpuscles; while the latter, the non- 
medullated fibres, end as a delicate plexus in the upper 
layers of the skin and rete mucosum. Both varieties of 
nerves accompany the more important bloodvessels. The 
larger nerve trunks come up from the subcutaneous con- 
nective tissue and divide at the corium, taking various 
directions according to the region they are to supply. 

* For further information, see Biesiadecki, Strieker's Human and Com- 
parative Histology, vol. ii. p. 225. 



26 ANATnMV OF THE SKIN. 

Medullated nerves. — Under this bead the Tactile and Pa- J 
cinian corpuscles are to be considered. 

TACTILB CORPUSCLES. 

These bodies are also called touch corpuscles, corpuscles 
of Meisener, and corpuscles of Wagner. They are oval or 
roundish in form, and are found situated in the papillae 
of the coriura, attached to medullated nerve fibres. As a 
rule they occupy the greater portion of the papillae, and are 
visible in prepared sections of skin as large, well-defined, 
firm-looking bodies, having a transversely striated or corded 
exterior. According to recent studies, especially those of 
Langerhans* and Thin,f they consist of a mass of nucleated 
cells, probably connective tissue, held closely together by 
delicate connective-tissue fibres. 

A medullated nerve fibre penetrates each corpuscle at its 
base, and winds itself with a variable course both around and 
throughout the interior of the structure, terminating within 
the corpuscle, as stated by Langerhans, in a club-shaped 
extremity. 

Papillae containing tactile corpuscles are termed sensory 
papilla; like the so-called vascular papillae, they possess 
bloodvessels, though of smaller dimensions. They have been 
demonstrated by Thin. Observers differ in their opinion 
as "to the existence of a membrane encapsulating the cor- 
puscle. The number of tactile bodies varies in different 
regions of the body; they are most numerous upon the 
fingers, especially upon the last phalanges. They are found 
also upon the palms and soles, as well as upon other por- 
tions of the body. Meissner, who devoted much time to the 
study of these corpuscles, ascertained that, out of four hun- 
dred papillae upon a square line of skin of the last phalanx 
of the finger, one hundred and eight were provided with 
tactile bodies. The same investigator states that they vary 
from &'» (.1068 mm.) to £'" (>2 136 mm.) in length, and that 
they measure about T y (.0534 mm.) in width. 



* Archiv fur Mikroscopische Anat., 1873, p. 730. 
f Jour, of Anat. and Phys., 1874, p. 30. 



ANATOMY OF THE SKIN. 



27 



Like the Pacinian corpuscles, they are to be considered as 
containing the terminal ends of medullated nerve fibre. 



PACINIAN CORPUSCLES. 

Pacinian corpuscles (so named after Pacini, an Italian 
anatomist), also called corpuscles of Vater, are quite large, 
well-defined, oval or olive-shaped bodies, found upon the 
cutaneous nerves. They occur in various regions, but are 
most numerous about the palms and soles, and fingers and 
toes, especially on the last phalanges. They vary greatly in 
size, averaging from \'" (1.068 mm.) to 2'" (4.272 mm.), and 
have their seat in the subcutaneous connective tissue. 




Fig. III.— Pacinian Corpuscle (drawn according to the views of Schafer), 
showing a medullated nerve fibre entering the corpuscle at its lower 
extremity; also the capsular envelope, the core, and the central fibre. 

Each Pacinian body is connected with a nerve trunk by 
means of a medullated nerve fibre, which enters the cor- 
puscle at its lower extremity and passes through the centre 
of the structure, terminating in one of several ways to be 
mentioned. According to Biesiadecki,* a bloodvessel of 
considerable size enters the corpuscle in the vicinity of the 
nerve fibre, and forms a plexus between the outer layers of 
the capsular envelope. 



*Loc. cit., p. 233. 



ANATOMY OF THE SKIN. 

The intimate structure of the corpuscle, following Schafer,* 
mav be regarded as consisting of* three parts,— the central 
fib Pej t ; and the capsular enclosure. The central 

fibre, B continuation of the entering nerve, retains a uni- 
form calibre throughout the body until it reaches its distal 
emity, where it usually becomes enlarged, terminating 
r in the form of an irregularly sized and shaped enj 
largeraent, or with pointed, fork-like processes. In structure 
it la composed of numerous fibrils, which are observed to 
cross one another very obliquely. 

T: . situated immediately around the central fibre, 

consists in its innermost portion of a homogeneous, non- 

oucleated Buhstance. According to Schafer, its outer part 

imposed of protoplasmic cells, like connective-tissue cor- 

puscles, cadi with a clear, oval nucleus. 

The capsular envelope, which surrounds the core, gives 
form and hulk to the corpuscle, and is made up of a number 
of concentrically arranged membranous layers, — the so-called 
coats of the Pacinian corpuscle. These lamina? have been 
commonly regarded as being composed of layers of flattened 
cells, together with both white and elastic connective-tissue 
fibres. According, however, to Key and Retziusf and the 
nt studies of Schafer, these coats have a peculiar struc- 
ture, each consisting of two layers of flattened cells, an 
irnal and an internal layer, placed, as it were, back to 
hack, between which exists the " so-called" intercapsular 
space, containing an albuminous fluid together with white 
and elastic fibres. 

The innermost layers of the corpuscle are compactly ar- 
ranged one upon the other, while the more external coats 
arc thicker and less closely held together. 

Viewed as a whole, the Pacinian body is to be looked 
upon as one of the forms of medullated nerve-fibre ter- 
mination. 

Non-Medullated Nerves.— The demonstration of these fibres 
in the skin is extremely difficult, and their presence can be 



* Quarterly Jour, of Micros. Science, April, 1875. 
f Schultze's Archiv. ix. 



ANATOMY OF THE SKIN. 29 

ihown only by the successful staining of their tissue by means 
)f ^old or osmic acid. From the researches of Biesiadecki* 
md Langerhansf we learn that they form a plexus in the 
>orium, composed of a few thick and many fine smooth and 
varicose nerve fibres. A few filaments come off" from this 
)lexus, which tend toward the mucous layer of the epidermis, 
)eneath which they pursue their course for some distance and 
hen enter it. Other fibres pass into the papillaa, where they 
livide, and ascend between the cells of the mucous layer, 
;erminating with fine bulbous extremities at about the third 
ayer of cells. 

MUSCLES. 

We encounter both striated and smooth muscular fibres 
n the skin. The former are found only in certain regions 
}f the body, as the face, arising from the deeper structures 
xnd terminating in the corium. The smooth muscular fibres 
3xist either as anastomosing plexuses running horizontally, 
as in the scrotum, or as fasciculi, as in connection with the 
bair follicles. As erectores 'pili or erectors of the hair, they 
Dccur in the form of flat bands, which, arising in the upper 
i>art of the corium, traverse it in an oblique manner and are 
attached to the hair follicle below the sebaceous gland. Many 
hairs possess two muscles, which pass around on either side 
of the gland. 

The muscles of the skin exist quite generally over the 
Dody, and are found to be highly developed upon the scalp, 
scrotum, and penis. The investigations of Kolliker show 
that they are arranged in circular layers about the areola of 
the nipple, becoming more marked from without inwards as 
'ar as the base of the nipple. In the nipple they form a close 
network. Contraction of these muscles causes the condition 
mown as cutis anserina, or goose-flesh 

PIGMENT. 

The general coloration of the skin depends upon a deposi- 
tion of pigment or coloring matter in the cells of the mucous 

* Strieker's Human and Comparative Histology, vol. ii. p. 235. 
t Virchow's Archiv, Bd. xliv., 2 and 3 Heft. 



ANATo.MV OF THE SKIN. 

r of the epidermis. It consists in a slight staining of the 
cells themselves, with a more intense coloring of their nuclei, 
and also upon the presence of line granules of pigment in the 
cells. One or more strata of the mucous layer may be the 
<>{ pigment cells, appearing microscopically as a dark 
line just above the papillary layer of the corium. The 
pigment layer is always located in the deepest cells of the 
mucous layer. The corium is never the seat of normal 
pigmentation. 

The color of the skin varies from white to black in dif- 
ferent races. It also varies from a light to a dark shade in 
different individuals of the same race, giving rise to the 
color of persons designated blondes and brunettes. In cer- 
tain regions of the body the skin is always relatively darker 
in color; as upon the scrotum, labia majora, perineum, 
nipples and areolae. This difference is due simply to an 
increase in the amount of the ordinary pigment, which is 
found to be largely developed in these localities. In the 
white race the pigment cells are for the most part yellowish 
white in color, which, together with the vascularity of the 
corium, gives the peculiar pinkish flesh tint of the skin. In 
the colored races, including the negro, the pigment layer is 
very highly developed, the whole of the mucous layer being 
more or less stained. The deepest strata of cells are always 
the most intensely colored. In these cases the horny layer 
of the epidermis is also somewhat darkened in hue. 

SWEAT GLANDS. 

The sweat or sudoriparous glands are convoluted bodies, 
situated deep in the corium, or, as is more often the case, in 
the subcutaneous connective tissue. They are tubular glands, 
twisted into the form of a knot, and open on the surface of 
the skin by means of a canal called the excretory duct. This 
duct begins at the gland, and ascends in a perpendicular 
manner through the skin and epidermis, passing between 
the papilla? of the corium, and opening out upon the surface 
of the epidermis. As it enters the epidermis it inclines to 
assume a Bpiral course, making a number of turns, and finalb 
terminates in a minute funnel-shaped aperture or jiore. Upoi 



ANATOMY OF THE SKIN. 31 

the palms and soles they are quite large, and can at times be 
seen with the naked eye. The duets vary in length according 
to the locality of the gland. 

The gland itself is a small, roundish body, yellow in color, 
varying in size as it occurs in one region or another of the 
body. In the axilla, where they form an almost continuous 
layer under the corium, they are found to be larger than any- 
where else, and attain a diameter of \'" (1.0G8 mm.) to \\'" 
(3.204 mm.). In other portions of the body they measure 
about \'" (.3560 mm.). 

Sweat glands exist in all parts of the skin, with a few 
exceptions. According to Kolliker and Biesiadecki, they 
are absent on the glans penis and prepuce. The former 
observer also denies their existence on the concave side of 
the concha of the ear and in the external auditory passage. 
They are very numerous, their number being estimated by 
Krause as considerably over two million.* The same observer 
places their number at about twenty-five hundred for both the 
palm and sole, and from four to tive hundred to each square 
inch upon the dorsal surface of the trunk and upon the cheek. 

In structure the sweat gland consists of a single tube, 
having about the same width throughout its length, which is 
convoluted and knotted into a ball, being held together by a 
loose connective tissue. The tube is made up of a sheath or 
external covering of connective tissue, containing internally 
a layer of columnar cells. 

The glands are extensively supplied with bloodvessels, 
which envelop them completely in a reticular manner. 

The secretion of the glands varies in quality according to 
their size and situation. The smaller ones onve forth a clear, 
transparent fluid, while the larger ones produce the same 
fluid together with fat cells and numerous fine granules 
with free nuclei. f This latter product is to be regarded as 
coming from the walls of the gland tubes. 

SEBACEOUS GLAXDS. 

The sebaceous or sebi parous glands are always situated in 
the corium; they are never found as far down as the sub- 

* Kolliker, loc. cit., p. 125. f lb., loc. cit, p. 127. 






ANATOMY OF THE SKIN. 



cutaneous connective tissue. As a rule they are connected 
with the hair follicles, into which they empty their secretion. 
isionally the ducts of the glands open upon the surface 
of the epidermis. 




'. 



Vi .. IV.— Showing the Structure of the Sebaceous Gland. 
iy layer of the epidermis. B, Mucous layer of the epidermis. C, Excretory duct of 
BOOB gland. D, The exterior structure of the gland. E, The interior of the gland, 
with sebaceous matter in situ. F, Shaft of a fine hair. 



They consist of a gland structure with a short excre- 
tory duct. The gland itself is a racemose one, made up of 
lobules, and has a pear-shaped form. At times it is divided 
into two or more separate parts or lobes, which unite at the 
duct. The sebaceous glands secrete a fatty product known 



ANATOMY OF THE SKIN. 33 

as sebum or sebaceous matter, which serves to oil the surface 
of the skin as well as the hairs. This product consists 
of a semi-fluid, oily mass, amorphous in character, which 
hardens into a tallow-like substance upon exposure to the 
air. Sebum is always mixed with numerous cells derived 
from the walls of the glands, which are being continually 
cast off. These cells are very abundant, and are epithelial 
in nature, resembling those of the rete mucosum. They 
contain a distinct nucleus, and are always more or less 
impregnated with fat. The excretory duct, as a rule, empties 
directly into the hair follicle, its wall being continuous with 
the external root sheath of the hair. 

The sebaceous glands occur in almost all parts of the body. 
Biesiadecki states that they are entirely absent in the palms 
and soles, on the dorsum of the third phalanges, and on the 
glans penis. On the other hand, both Kolliker and Neu- 
mann assert that they are present upon the glans penis. My 
own experience inclines me also to this view. 

The size of the glands is very variable, averaging from 
T y" (.2136 mm.) to V" (2.136 mm.). The largest sebaceous 
glands are those found in the eyelids, — the Meibomian glands. 
They exist in great numbers throughout the scalp, each hair 
being, as a rule, supplied with two glands. About the 
scrotum, pubes, mons veneris, labia majora, the glands are 
even more numerous, from four to six often being connected 
with one hair. 

HAIRS. 

Hairs are fine, long, rounded, compact bodies, having their 
seat in the so-called hair follicles, — depressions in the skin. 
Three kinds of hair are recognized: long hair, as that of the 
scalp; short, thick hair, as that of the eyebrows; and very 
fine, soft hair, called lanugo, found upon the face, trunk, and 
other regions. 

In considering the hair we distinguish two portions, — the 
shaft, which is free, and protrudes beyond the surface of the 
skin, and the root, the part contained within the skin. The 
shaft is usually long and straight, tapering off* to a point as 
it approaches its end, while the root is found to be thicker 

3 






ANATOMY OF THE SKIN. 



and to terminate in a bulb-shaped expansion, termed the 

hour bulb. 

In minute structure the hair consists of the cortical 
substance and the cuticle; another portion, the medullary 
substance, may also be mentioned here, although its presence 
is not constant. 






Fig. V.— The Hair and the Hair Follicle. A, Shaft of the hair. B, The 
root of the hair. C, Cuticle of the hair. D, Medullary substance of the hair. 

E, External layer of the hair follicle. F, Middle layer of the hair follicle. 
G, Internal layer of the hair follicle. H, Papilla of the hair. I, External root 
sheath. J. Outer layer of the internal root sheath. K, Internal layer of the in- 
ternal root sheath. 

The cortical substance, termed also hair substance, consti- 
tutes the bulk of the hair, and is composed of a number of 
elongated, spindle-shaped, flat filaments or bundles, longi- 



ANATOMY OF THE SKIN. 35 

tudinally striped, containing pigment granules, which give 
it a punctate appearance. These filaments are further made 
up of long, flat, nucleated fibre cells, which adhere so closely 
together as to be separable only by the employment of 
reagents. In white hair the cortical substance is without 
pigment, and is transparent. 

The hair bulb, or root proper, surrounds the hair papilla at 
the base of the follicle. It is a loose, spongy structure, and 
is composed of nucleated cells similar to those found in the 
deep strata of the mucous layer of the epidermis. Small 
granules, either colorless or pigmented, according to the color 
of the hair, are present and give the structure a speckled 
appearance. At the point where the hair bulb joins the 
straight portion of the root, the cells composing the bulb pass 
imperceptibly into the fibre cells of the cortical substance. 

The cuticle is a delicate membrane, which completely in- 
vests the cortical substance and serves to bind its bundles 
firmly together. It is adherent to the hair, and gives it a 
reticulated, crossed, seal}' appearance, not unlike the scales 
upon a fish. When treated with alkalies it is seen to become 
detached from the hair substance, and to consist of numerous 
small, flat, transparent cells or plates, without nuclei. They 
are analogous to the cells of the horny layer of the epider- 
mis, and serve a like purpose. 

The medullary substance is wanting in some hairs. It is 
usually present in the short and thick hairs, as well as in 
the long hairs of the scalp ; it is absent in lanugo. When 
present i4: is seen as a broad, colored line or cord, running 
longitudinally through the centre of the hair, commonly 
extending throughout its whole length. In structure it 
consists of cells, rectangular or oblong in shape, containing 
nuclei and fatty granules. They may be seen to advantage 
with the aid of an alkali. Air vesicles are frequently found 
in the medullary substauce. 

HAIR FOLLICLE. 

The hair follicle is an elongated sac, from V" (2.136 mm.) 
to 3'" (6.408 mm.) long, dipping down into the corium and 
subcutaneous connective tissue, for the accommodation of the 



ANATOMY OF THE SKIN. 

hair. It 18 to be viewed as a continuation of the epidermis 
and corium. It is cylindrical in form, tending to enlarge at 
its lower extremity. In structure it consists of three layers, 
rnal, middle, and internal. 

ternal layer (termed by Kolliker the external fibrous 

determines the form of the follicle; it is the most im- 

portant and thickest layer, and consists of connective-tissue 

fibres which run parallel with the course of the hair, blend- 

ibove in the papillary layer with the fibres of the corium, 

and terminating below, around the hair bulb, in the form 

of an ovate prolongation into the subcutaneous connective 

ie. It is supplied with an artery, a vein, and medullated 

nerve fibre. 

The middle layer (the internal fibrous coat of Kolliker) is less 
extensive than the external layer, and is seen to be made up 
of transverse connective-tissue fibres with elongated nuclei. 
Bloodvessels have been found here, but no nerves. 

The internal layer (called also vitreous membrane, and struc- 
tureless membrane) is not acted upon by either acids or alkalies. 
It is a transparent tissue. Its outer surface is smooth; its 
inner surface is marked with delicate transverse lines. Ac- 
cording to Biesiadecki, although perfectly homogeneous on 
section, it shows, when viewed on the flat surface, transverse, 
oblkpie, decussating fibres, together with ill-defined round 
nuclei. It is without vessels or nerves. 

At the base of the follicle rises the papilla of the hair, a 
conical or ovate, smooth, well-defined body, about T V" (.1424 
mm.) long, which is seen to protrude itself into the hair. It 
springs from the connective tissue of the follicle, and con- 
sists of connective tissue together with round nuclei and 
nucleated cells. Biesiadecki has demonstrated that two 
small arteries enter the papilla, and that these usually unite 
to form a single trunk towards the summit and then again 
divide and find their way out in the form of veins. The 
same observer has been able to trace non-medullated nerve 
fibres as far up as the neck of the papilla. 

There are two root sheaths, an external and an internal; 
they are made up of a number of layers. 



ANATOMY OF THE SKIN. 37 

The external root sheath is simply a continuation of the 
raucous layer of the epidermis, which extends down the 
hair as far as the bulb. As it approaches the bulb it be- 
comes narrower, finally terminating in a point, consisting of 
a single row of cells. On the outside it adjoins the vitreous 
membrane of the follicle. Langerhans claims to have found 
nerve structure here, the same as in the mucous layer of the 
epidermis. 

The internal root sheath is a transparent, elastic, firm mem- 
brane investing the root from the openings of the sebaceous 
glands down to the hair bulb. It is composed of two layers, 
an outer and an inner, the first being connected externally 
with the external root sheath, the latter with the cuticle of 
the hair. 

The outer layer consists of elongated, highly refractive, non- 
nucleated cells, lying parallel to the long axis of the hair. 

The inner layer adjoins and is attached to the cuticle of the 
hair. It consists of non-nucleated, broad cells, somewhat 
thicker than those of the cuticle of the hair. 

Hairs occur upon all parts of the body, except the palms 
and soles, eyelids, backs of the last phalanges of the fingers 
and toes, lips, and inner surface of the prepuce and glans 
penis. They are seen to be seated in the skin in a more or 
less oblique direction, varying with the region of the body. 
They vary both in thickness and in length, according to 
locality; they are shortest and finest in the delicate lanugo 
found upon the face and trunk, and longest and coarse.-t 
upon the scalp and beard. The number of hairs upon the 
body likewise varies considerably in different localities; also 
in different individuals. As a rule, the lighter the hair in 
color the more numerous will they be found. 

AVilsou* calculates the number of hairs of the scalp to be 
about one thousand to the square inch, or one hundred and 
twenty thousand to the whole scalp ; other calculators make 
the number less. The difference depends upon the number 
of follicles present; also the number of hairs arising from 
each follicle. 

* Diseases of the Skin. London, 1867, p. 36. 



ANATOMY OF THE SKIN. 

The general color of the hair varies extremely in different 
- and in individuals. It depends upon the presence of 
lent in the hair filaments, in the form either of granules 
or of a diffused coloration. It is also influenced by the pres- 
ence of air vesicles, which may occur, Biesiadecki thinks, 
either between the cortical and medullary substances or in 
their interior. 

Hairs are remarkably elastic, and admit of great exten- 
sion ; they are also very strong, and are capable of supporting 
considerable weight without breaking. When cut they grow 
again rapidly until they have assumed their determinate 
length. They absorb and give off water readily; they also 
take up fatty and oily substances. 

In structure they contain no bloodvessels ; they are nour- 
ished from their papillae. In chemical composition they 
consist of a nitrogenous substance, containing sulphur, fat, 
pigment, and mineral salts. They retain their characteris- 
tics for a very long time, and are the last portion of the 
body to give way to decomposition. 

NAILS. 

The nails are hard, horny, elastic, transparent structures, 
which are imbedded in the skin upon the last phalanges of 
the lingers and toes. They are rounded or quadrilateral 
bodies, and are curved from side to side. They have four 
borders, one of which only, the anterior, is free; the poste- 
rior and lateral borders are sunk in the flesh. The posterior 
portion of the nail, situated in the skin, is termed the root, 
while the exposed part is called the body. 

Around the lateral and posterior borders of the nail, at 
the point where the skin joins the nail, there exists a well- 
defined groove. The corium upon which the nail rests is 
called the bed or matrix; it corresponds in form to the nail, 
to which it is closely adherent. The matrix is a part of the 
corium, and presents peculiar ridges, upon which are seated 
the papillae, directed somewhat forward. It is a dense tissue, 
containing an abundance of elastic fibres and but little fat. 
The bloodvessels form a plexus in the upper part of the 
corium, supplying the papillae, and also a finer plexus in the 



ANATOMY OF THE SKIN. 39 

lower portion, devoted to the matrix itself. According to 
Biesiadecki,* numerous medullated nerve fibres lie in the 
subcutaneous tissue of the nail bed, which, losing their 
medullary sheath at about the level of the corium, run ver- 
tically to the surface. 

A defined whitish substance, surrounded anteriorly by a 
convex line, is usually present in the matrix, just in front of 
the posterior groove. It is crescentic in shape, and is called 
the sernilunula. 

In structure the nail must be regarded as modified epi- 
dermis. Like it, it is divided into two layers, a horny and a 
mucous layer. The former constitutes the greater portion 
and substance of the nail, forming its exterior as well as its 
free edge. 

The surface of the nail is smooth and glistening, and con- 
tains longitudinal strise, which are parallel, running from the 
root to the free edge. 

In order to study the intimate structure of the nail it is 
necessary first to employ reagents. It is then found to be 
made up of numerous, closely connected plates, which may- 
be further resolved into nucleated, polygonal, flat cells. 
Excepting in the presence of the nuclei, they resemble the 
cells of the horny layer of the epidermis. 

* hoc. cit., p. 260. 



SYMPTOMATOLOGY. 

Diseases of the skin exhibit themselves in the form of 
symptoms, which are either of an objective or of a subjective 
nature. 

Objective symptoms are those which consist of certain 
appearances which manifest themselves upon the surface, 
and are for the most part the result of structural alteration 
in the tissues. They are capable of ocular demonstration. 

Subjective symptoms, on the other hand, relate solely to 
sensation, of which the patient alone is able to take cog- 
nizance. The former are much the more numerous, and 
constitute by far the more important group. 

OBJECTIVE SYMPTOMS. 

Under this head are to be studied the. various lesions 
which occur in the skin. These may be divided into those 
which show themselves as primary forms of disease, termed 
'primary lesions, and those which exist either as the result 
of primary lesions or from other causes, designated second- 
ary lesions. The importance of obtaining a just appreciation 
of these morbid changes cannot be over-estimated. Upon 
their recognition depends the ability to establish correct 
diagnoses. 

PRIMARY LESIONS. 
MACULE. 

Syn. Macules; Spots; Germ., Flecke; Fr., Taches. 

Maculae are variously sized, shaped, and colored portions 

OF ALTERED SKIN, UNACCOMPANIED BY ELEVATION OR DEPRESSION. 

They are of various sizes; they may be as small as a pin- 
head or as large as a hand. In outline they are usually 

40 



SYMPTOMATOLOGY. 41 

roundish, but they may also be irregular in shape. In color 
they vary exceedingly; they may, in fact, be of any color, 
the more common, however, being red and yellow. They 
are the product of diverse causes, and consequently repre- 
sent a number of pathological conditions. 

The simplest variety of macule is that caused by hyper- 
semia and called erythema, examples of which are of con- 
stant occurrence in connection with numerous disorders. 

Maculae may also be the result of hemorrhage into the 
tissues of the skin, when they appear as reddish or blackish 
marks, which do not disappear under pressure. 

Permanent vascular growths in the skin, as naevi, are also 
included as maculae. 

Alterations in the pigmentary function of the skin give 
rise to maculae, which may be due to either an increase or 
a deficiency of the normal coloring matter. The disease 
vitiligo offers an instance where the spots are caused by an 
increase as well as a deficiency of the pigment, both atrophy 
and hypertrophy taking place side by side. The yellowish 
maculae termed chloasmata, observed for the most part about 
the face of women, are occasioned by the presence of an ex- 
cessive amount of the normal pigment. Another form of 
the macule, due to the same cause, is found in lentigo or 
freckle. 

When abnormal coloring of the skin involves the whole 
or a large portion of the surface in a uniform manner, the 
condition is designated a discoloration. Examples of this are 
observed in jaundice, and in the staining of the skin result- 
ing from the internal use of nitrate of silver. 

Maculae are evanescent or permanent according to their 
cause. They disappear or remain under pressure, as they 
are of one kind or another. 

They may or may not be accompanied by subjective symp- 
toms. 

PAPULA. 
Syn. Papules ; Germ., Knotchen ; Fr., Papules. 
Papula are circumscribed, solid elevations of the skin, 
varying in size from a pin-head to a split pea. 

They are of various shapes; some are acuminated, some are 



12 SYMPTOMATOLOGY. 

rounded, while others are flat and angular. They are en- 
countered in numerous diseases; are due to a great number 
auses; and have their seat in different structures of the 
skin. They may be situated in the corium; in connection 
with sebaceous glands; or about the hair follicles. 

Papules may or may not be inflammatory, according to 
their origin and mode of development. Their color varies; 
they may be reddish, or they may be whitish. 

Papules are of many varieties, the more prominent of 
which are the following. 

The commonest papule is that which consists of a circum- 
scribed plastic exudation in the skin. It finds its typical 
expression in papular eczema. Inflammatory papules may 
or may not undergo metamorphosis into other lesions ; thus, 
not infrequently they pass on into vesicles and pustules, or, 
they may break down and become ulcers, as in syphilis. 

Another variety of papules is made up of accumulations 
of epidermic cells, arranged concentrically around the en- 
trances of the hair follicles ; they form solid conical eleva- 
tions, and are seen in lichen pilaris. 

Still another kind of papule is formed about the sebaceous 
glands, consisting of a circumscribed collection of sebum, 
producing a solid, whitish, semi-globular elevation, as ob- 
served in milium. Closely allied to this formation is that 
which occurs in comedo, which must also be considered as 
a papule. 

Hemorrhage into the skin at times gives rise to papules, 
as in purpura papulosa. 

Papules may also be formed by hypertrophy of the normal 
structures of the skin, as the papillae, examples of which may 
be observed in ichthyosis, warts, etc. 

The duration of papules varies with their character; some 
last only a few days, while others are permanent. They may 
disappear by absorption, as in the case of most of the inflam- 
matory varieties, or they may be removed by mechanical 
means, as in milium. Inflammatory papules are in the 
course of their evolution frequently surmounted by accumu- 
lations of fine scales, more particularly during the stage of 
decline. When scales are present in any quantity, the lesion 



SYMPTOMATOLOGY. 43 

receives the name of a squamous papule; this condition is of 
very common occurrence in syphilis. The disappearance of 
inflammatory papules, especially those of long standing, is 
apt to be followed by pigmentary deposit. 

Papules may or may not be attended by itching, this 
symptom, as well as others of a like kind, depending alto- 
gether upon their nature; thus, those of eczema are remark- 
able for the violence of the itching which they occasion, 
while, on the other hand, those of milium or lichen pilaris 
give rise to no inconvenience whatever. 

VESICUL.E. 
Syn. Vesicles; Ger-m., Blaschen ; Fr., Yesieules. 
VESICULjE are circumscribed, rounded elevations of the 

EPIDERMIS, VARYING IN SIZE FROM A PIN-POINT TO A SPLIT PEA, 
CONTAINING A CLEAR SEROUS FLUID. 

They are of different colors, according as their contents 
are pure serum, sero-purulent matter, or serum mixed with 
blood. When recent and typical in character, they possess 
a yellowish hue. They may be either fully distended with 
fluid or only partially so ; their walls may be either tense or 
flaccid. As a rule they rupture readily, and discharge their 
contents over the surrounding surface. Certain vesicles, 
however, as those of herpes zoster, are tenacious, and do not 
break unless exposed to violence. 

In form vesicles are rounded and possess either a dome- 
like roof or are somewhat acuminated. They may have 
either an even, rounded surface, or they may have a slight 
depression on their summit. 

Anatomically the vesicle has its seat between the mucous 
and horny layers of the epidermis. Vesicles do not remain 
as such for any length of time ; rarely for more than a few 
days. They either rupture, — the fluid becoming a crust, — 
or they retain their contents, which pass into a purulent con- 
dition, and thus become pustules. The changes which they 
undergo vary in different diseases. 

Vesicles rarely occur singly, but almost always in numbers, 
either in the form of aggregations, as in eczema, or in distinct 
groups, as in herpes zoster. They may occur upon all parts 



1 I SYMPTOMATOLOGY. 

of the body; more especially upon those portions where the 
epidermis is delicate and soft. They are usually accompanied 
by burning and itching sensations; at times, however, such 
symptoms arc absent. 

BULLAE. 

$!/h. Blebs; Germ., Blasen ; Fr., Bulles. 

BULUE ARE IRREGULARLY-SHAPED ELEVATIONS OF THE EPIDER- 
MIS, VARYING IN SIZE FROM A SPLIT PEA TO A GOOSE-EGG, CONTAIN- 
ING A CLEAR OR OPAQUE FLUID. 

They vary exceedingly in size, and have no definite form. 
Large and small bullae may occur simultaneously side by 
side. They may appear either singly or in numbers; they 
are never so numerous as vesicles, nor do they ever incline 
to form into distinct groups. 

They are usually of a bright yellow color; when their 
contents become turbid, they are whitish ; when they contain 
blood, they are reddish. The fluid of bullae is albuminous 
and offers an alkaline or neutral chemical reaction. 

Bullae usually possess strong walls, and do not tend to 
rupture spontaneously. They are commonly distended to 
their utmost capacity; in particular instances, however, they 
are only partially filled and remain flaccid. At times they 
break before they are perfectly formed, leaving their shat- 
tered walls attached to the skin in the form of shreds ; this 
process takes place in pemphigus foliaceus. 

The walls of bullae rise up directly from the surface of 
apparently healthy skin, without, as a rule, marked signs 
of inflammation; occasionally areolae are present. Like ves- 
icles, blebs have their seat in the layers of the epidermis. 
Their intimate structure also corresponds to that of vesicles. 
They are not commonly attended by marked itching or burn- 
ing seusations, except in their early stages, or in those cases 
where they are in large numbers. 



SYMPTOMATOLOGY. 45 

PUSTULE. 

Syn. Pustules ; Germ., Pusteln ; Fr., Pustules. 

Pustule are circumscribed, rounded elevations of the epi- 
dermis, VARYING IN SIZE FROM A PIN-POINT TO A FINGER-NAIL, 
CONTAINING PUS. 

They either originate as pustules, or become so by transition 
from vesicles or papules. Inasmuch as they always contain 
pus, they have a yellow, opaque color; not infrequently they 
also contain blood, in which event they possess a dark reddish 
color. 

There are several well-defined kinds of pustule ; their chief 
difference resting in their mode of development and struc- 
ture. 

The pustule of acne has its seat in a sebaceous gland; 
that of ecthyma and of pustular eczema, about the papillary 
layer; while that of variola is situated between the layers of 
the epidermis, as in the case of the vesicle. 

The course and duration of pustules differ according to 
their character; they all incline to a rapid termination. 
They either burst, forming a thick, yellowish or dark crust, 
or desiccate without rupture, leaving a dry, friable crust. 
Pustules may or may not be followed by cicatrices; this de- 
pends upon the anatomical nature of the pustule, and also 
upon the extent to which the process has involved the skin. 
The scars resulting from variola, as well as from acne, are 
well known. 

Pustular are seldom accompanied by prominent subjective 
symptoms; very frequently they are altogether absent. 

WHEALS. 
Syn. Pomphi; Urticse : Germ., Quaddeln. 

Wheals are firm, flat, elongated or rounded, slightly 
raised elevations, of an evanescent character. 

Their size varies extremely; they may be as small as split 
peas or as large as the palm of the hand. They are apt to 
appear in great numbers, and exhibit a decided inclination to 
run together; by this process of coalition large surfaces become 
involved in continuous patches. In form, wheals ordinarily 



j ( ; SYMPTOMATOLOGY. 

manifest themselves as bean-shaped or oval elevations, tend- 
ing to assume an elongated rather than a rounded shape; 
they also occur in the form of lines or stripes. Their color 
inllv whitish or pinkish, with more or less of an areola. 
In duration they are evanescent; they form very rapidly, 
often in a few moments, and, remaining a longer or shorter 
time in statu quo, disappear in almost as rapid a manner as 
they came. 

They have their seat in the upper layers of the skin, and 
arc produced by a sudden effusion of fluid into the meshes 
of the corium. They may contain serous fluid, as in simple 
urticaria, or a mixture of serum and blood, as in purpura. 
The typical wheal is seen in urticaria. 

Wheals are always accompanied by marked tingling and 
itching sensations, which are often very distressing. 

TUBERCULA. 

S;/n. Tubercles: Germ., Knoten ; Fr., Tubercules. 

Tubercles are firmly-seated, solid elevations of the skin, 
varying in size from a split pea to a cherry. 

In shape they are rounded, but possess no definite form ; 
they may be semi-globular, conical, flat, or of irregular out- 
line. Their color is usually reddish ; this feature, how T ever, 
depending upon their nature. In those cases where they 
are due to inflammatory products or to new formations, they 
are apt to exhibit a deep red color. Tubercles are ordinarily 
of firm consistence, often hard to the touch, and have their 
seat in the corium and subcutaneous connective tissue. In 
minute structure they are similar to papules, frequently being 
in reality exaggerated papules involving deeper tissues and 
a more extended amount of surface. They are the result of 
various causes, as in the case of papules, but are produced 
in great part by the cellular neoplasmata. Syphilis, leprosy, 
and carcinoma all give rise to marked examples of tubercle. 
They undergo various changes in their evolution, according 
to their nature and circumstances; they are either absorbed, 
or break down and ulcerate, or they may establish them- 
selves and remain permanent. 



SYMPTOMATOLOGY. 47 



TUMORES. 
Syn. Tumors ; Phymata ; Germ., Knollen ; Fr., Tumeurs. 
Cutaneous tumors are variously sized, shaped, and consti- 
tuted FIRM PROMINENCES. 

They are of all sizes, from a pea to an egg, and larger. 
They are usually of a semi-globular form, and are either 
connected to the skin with a broad base, as in sebaceous 
molluscum, or are pedunculated, as in many cases of fibrous 
molluscum. They are more or less well denned, according 
to their nature. Their color is very often the same as that 
of the adjacent skin. Tumors rise above the surrounding 
skin to a variable elevation, and, on the other hand, extend 
more or less deeply into the tissues beneath. They are 
occasioned by a great variety of causes: alterations in the 
sebaceous glands; new formations in the corium, connective 
tissue, bloodvessels, and lymphatics; all give rise to their 
development. They may or may not be painful. 

SECONDARY LESIONS. 
CRUSTS. 
Syn. Crustce ; Germ., Borken ; Krusten ; Fr., Croutes. 
Crusts are effete masses of dried material composed of 
the products of disease of the skin. 

They are variable as to size and form, their features 
depending entirely upon the nature of the process which has 
occasioned them, as well as upon the length of time which 
they have existed; they may be large, thick, and bulky, or 
they may be thin and flat. They are adherent to the skin, 
or loose, according to their age and the nature of the dis- 
ease. In color they are usually yellowish or brownish ; they 
may also be greenish, reddish, and blackish. They are, for 
the most part, formed by the desiccation of exuded fluids, as 
serum, pus, and blood. Several distinct varieties of crust are 
observed. Those resulting from an open, serous-discharging 
surface are light yellow in color, friable in consistence, and 
usually without definite outline or bulk, as in eczema; those 
following the breaking down of pustules are darker, more 



SYMPTOMATOLOGY. 

tenacious, and thicker, as in ecthyma. The crusts of syphilis 
arc firmer and less friable in structure, often greenish in 
color, and, when recent, are seated upon an ulcer. Reddish 
or blackish crusts always contain more or less of blood. 
Sebaceous crusts, as those of seborrhoea, are light yellow, 
dirty yellow, or blackish in color; they are flat, lamellated, 
adherent to their bed, and have both a greasy appearance 

and feel. 

SCALES. 

Syn. SqnamflB; Germ., Schuppen; Fr., Squames. 

Scales are dry, laminated masses of epidermis which have 
separated from the tissues beneath. 

They vary greatly in size and form ; they may be large and 
thick or small and thin ; they may be abundant or scanty. 
In consistence they are always dry and of a horny nature; 
they possess a harsh feel, and are more or less brittle, with a 
tendency to separate and to break up into their more minute 
structure. Their color is usually whitish ; at times it is 
yellowish. The quantity of scales formed and thrown off 
varies with the morbid process; the amount and variety of 
inflammatory action present also influence the degree of 
desquamation. 

Scales are at times formed in large, bulky lamellae or plates, 
as in psoriasis ; iu other cases, as in dry seborrhoea, they con- 
sist of fine dust- or bran-like particles. They are due to a 
variety of causes. The diseases producing them may have 
their seat solely in the epidermis, as in the vegetable para- 
sitic diseases, or they may be located in the deeper structures, 
a3 in the exudative affections. 

Scales are apt to form in all cases in which there is want of 
proper nutrition in the skin ; they are the product of numer- 
ous pathological changes. 

EXCORIATIONS. 
St/71. Excoriationes ; Germ., Hautabschiirfungen j Fr., Excoriations. 
Excoriations are losses of tissue occurring in the super- 
ficial LAYERS OF THE SKIN. 

Their seat is usually in the epidermis, extending to the 
mucous layer; not infrequently the papillary layer of the 



SYMPTOMATOLOGY. 49 

coriura is involved. They comprise slight wounds and abra- 
sions of the skin, lacerations, scratch marks, etc. As a rale 
they heal readily and without leaving scars. 

In appearance they present a variety of forms, as they 
happen to have been produced by one cause or another. 
Ordinarily they consist of torn lines with shreds of epidermis, 
showing reddish, moist surfaces, oozing minute quantities of 
serum and blood, which have a tendency to dry into crusts. 
They may be present in connection with an eruption of a 
pruriginous nature, or they may exist independent of disease, 
as simple wounds of the epidermis produced by mechanical 
causes. 

Scratching, on the part of the patient, is the direct cause 
of the vast majority of excoriations. The symptoms which 
give rise to the desire for scratching are numerous, and are 
intimately connected with a large number of diseases. All dis- 
orders of the skin accompanied by nerve irritation, whether 
from an internal or an external cause, occasiou more or less 
itching, and consequent scratching. If the itching be in- 
tense, the scratching will be violent and the marks propor- 
tionally severe and deep ; if slight, as a rule, there will be 
but little and the lesions superficial. Excoriations occur most 
abundantly in eczema, and in scabies aud phtheiriasis. All 
skins are not affected to the same extent by the act of scratch- 
ing ; in some the lesions are readily produced, while in others 
the tissues resist the injury. 

If violent scratching and rubbing be continued for a long 
period, the skin becomes more or less inflamed, resulting in 
considerable infiltration and thickening. This state of the 
integument may be frequently observed in those who have 
been troubled for a long time with phtheiriasis. Excoria- 
tions play a very important role in many diseases of the 
skin, and should always receive attentive consideration. 

FISSURES. 
Syn. Rhagades 5 Germ., Hautsclirunden ; Fr., Fissures. 
Fissures are linear wounds having their seat in the epi- 
dermis OR CORIUM. 

They commonly occur about the well-marked normal 

4 



SYMPTOMATOLOGY. 

furrows of the skin, as about the fingers; they are also 
encountered in other regions. They assume various sizes, 
and appear as long, narrow, more or less deep, reddish, linear 
openings or clefts. They are either the result of a diseased 
condition of the tissues, as in eczema, or they may be caused 
by local irritants, as cold and chemical agents, acting inju- 
rious v upon the epidermis. Any portion of the surface which 
la liable to extreme tension may become the seat of fissures. 
They are painful, and interfere with the natural movements 
oi' the part. 

ULCERS. 
Si/)i. Ulcera; Germ., Geschwlire ; Fr., Ulceres. 

Ulcers of the skin are irregularly sized and shaped ex- 
cavations OF THE CUTANEOUS TISSUES, THE RESULT OF DISEASE. 

They vary extremely as to size and shape; they may be 
no larger than a pin-head, or as large as a hand, and even 
larger; in outline they are usually roundish. They may 
be superficial or deep ; not infrequently they extend into 
the subcutaneous structures. They present a more or less 
moist and discharging surface, which may or may not be 
crusted. Their bases are smooth or uneven, reddish in 
color, and are covered with a grayish, yellowish, or reddish 
secretion, which may be either abundant or scanty, accord- 
ing to the nature of the morbid process. Their edges are 
usually defined; not infrequently they are abrupt; at times 
they are markedly everted. Ulcers are the result of previous 
disease, and occur in the course of a number of disorders, 
chief among which are syphilis, lupus, carcinoma, carbuncle, 
and furuncle. Their duration is variable ; they are seldom 
stationary, but show, on the contrary, a decided disposition 
to undergo change. Many tend to enlarge ; others mani- 
fest an inclination to heal. When repair takes place it is in 
the form of a cicatricial tissue, which remains permanently. 
Ulcers are usually painful. 

SCARS. 
Syn. Cicatrices ; Germ., Narben ; Fr., Cicatrices. 

Scars are new formations occupying the place of former 
normal tissue. 

They have a glistening, contracted appearance, and are 



SYMPTOMATOLOGY. 51 

surrounded by normal skin, into which they imperceptibly 
blend. To the feel they are usually smooth and soft; they 
may, however, be quite hard. They possess different forms 
and characters, according to the disease which has occasioned 
them ; they may be on a level with the skin, or, as is more 
often the case, somewhat depressed ; they may also be raised. 
At times they are linear or cord-like, and, in other instances, 
crab-shaped and puckered. Their color is usually whitish; 
but this varies, for if recent they may be pinkish or yellow- 
ish, while if old they may be gray or brownish. They con- 
sist of connective-tissue elements, and do not contain any 
of the normal structures of the skin, as hairs, glands, and 
papillae. 

Scars may be the result of disease or of injury. They 
are known to follow all of the ulcerative diseases, and also 
all injuries involving loss of substance, as burns, scalds, and 
wounds, also the application of caustics. 

Although scars result from a variety of causes, many of 
them are found to be very similar in character; hence they 
cannot be said to be positively indicative of the process 
which has occasioned them. At the same time they not 
infrequently possess certain features, — as, for example, out- 
line, number, size, texture, and location, which point to the 
original disease. 

Scars are apt to be permanent, continuing to exist through 
life with but little alteration; occasionally they undergo 
change. They are, for the most part, painless; in rare 
cases, however, they are the source of pain. 

GENERAL SYMPTOMS. 

All of the existing lesions present in a given case of dis- 
ease, viewed as a whole, constitute what is known as an 
eruption. 

An aggregation of lesions, whether of the same or of dif- 
ferent character, go to make up what is termed a patch of 
disease. 

The individual lesions of a disease may all be of the same 
kind, as, for example, all papules, in which event they are 
uniform; or they may be different, of two or more kinds, 



52 SYMPTOMATOLOGY. 

macules, papules, and vesicles, for example, all being present, 
when they are said to be multiform. They may, moreover, 
be isolated or discrete, or they may be so numerous as to 
be closely crowded or confluent. 

The following expressions, descriptive of peculiar forms of 
m, are used in connection with certain diseases, more es- 
pecially in those cases in which the lesions are both uniform 
and numerous: when small, millet-seed sized, miliar is ; when 
pointed, acuminatus ; when of the size and shape of a pea or 
bean, laiticularis, etc. .Common examples are found in the 
miliary papular syphiloderm, in acuminated warts, and in 
the lenticular papular syphiloderm. 

The terms neonatorum, infantilis, adultorum, senilis, etc., are 
frequently convenient to express concisely the time of life 
at which the disease occurs; for example, the sclerema of 
the new-born is called sclerema neonatorum; the eczema of 
infants, eczema infantile, etc. 

Distribution. — Great variation exists in the distribution of 
the lesions; they may occupy the whole or the greater part 
of the surface, or they may be localized to a small, cir- 
cumscribed area. They may further appear aggregated, in 
distinct patches — aggregates, or they may be disseminated — 
disseminatus. 

When an eruption involves the whole surface, it is said to 
be universal; when various parts, without regularity of distri- 
bution, it is called diffused. 

Configuration. — The lesions of the skin form themselves 
into a great variety of figures or patterns. Some of these 
are peculiar, and are characteristic and constant symptoms of 
certain diseases, while others are common to many diseases. 
In still another class of atfections they manifest themselves 
without attempt at configuration. 

The various outlines or forms assumed by individual 
lesions or by patches of disease, are designated by the fol- 
lowing suggestive terms. 

When the lesions occur discretely, in the form of small, 
pin-head sized points, the condition is termed punctatus; 
when they are of the size of drops, guttatus; if as large as 
pieces of coin, nummularis. 



SYMPTOMATOLOGY. 53 

When a patch, of whatsoever disease, presents a circular 
form, it is called circinatus ; when in the form of a ring, 
annulatus or annularis. "When the lesions appear in concen- 
tric rings, one within the other, the condition is expressed 
by the word iris, as herpes iris. 

Occasionally patches are encountered whose margins upon 
one side appear unusually sharp and well defined against the 
sound skin ; to these the name marginatus is given. 

When the patches are circumscribed and are marked by an 
abrupt line of demarcation, the word circumscriptus is used. 

If the patches arrange themselves in such a manner as to 
form winding or gyrate markings, the term gyratus is em- 
ployed. 

The designation serpiginosus is applied to those forms of 
disease, especially ulcers, which pursue their course in a 
creeping, serpentine manner. 

The state of an eruption, as to its striking feature, is often 
denoted as follows: hyperlrophicus, used in connection with 
hypertrophies and new growths, is employed to indicate an 
exuberant or hypertrophic condition ; exulcerans, when the 
process of ulceration is extensive; humidus or madidans, when 
moisture is present, as in eczema; and siccus, when there is 
absence of moisture, as in seborrhoea. 

Locality. — The regions of the body invaded vary with the 
disease. Certain affections are peculiar in that they attack 
only particular localities ; some possess a decided preference 
for this or that region, while others exhibit no elective point 
of manifestation. 

In some affections the extensor surfaces of the extremities 
are almost exclusively involved, while in others the flexor 
surfaces are the chief seat of disease. 

The terms capitis, facialis, brachialis, femoralis, abdominalis, 
palmar is, plantaris, etc., are conveniently used to denote the 
exact region involved; as, for example, eczema capitis, herpes 
zoster facialis, etc. 

Symmetry. — Diseases may or may not be symmetrical. 
The inflammatory diseases in particular show a marked 
tendency to appear symmetrically upon either side of the 
body. Other affections likewise very frequently manifest this 



5 J SYMPTOMATOLOGY. 

symptom. The symmetry of an eruption is seen to best 
advantage upon the extremities. 

Color. This varies with the nature of the pathological 

process. It also varies greatly according to the stage of the 
disorder. It is, moreover, influenced by external agencies. 

When an affection is characterized by a prominent and 
uniform color, whether evanescent or permanent, it is at 
times designated by a term descriptive of this peculiarity; 
in this manner the adjectival words albidus, ruber, fiavescens, 
melanodes, etc., are affixed to diseases, e.g., eczema rubrum. 

SUBJECTIVE SYMPTOMS. 

Diseases of the skin may or may not be accompanied by 
subjective symptoms. More or less heat is present in all of 
the hypersemic and inflammatory affections, notably in those 
running an acute course. Sensations described as burning, 
tingling, and smarting also not infrequently attend the same 
class of diseases. Itching, however, is the most prominent 
by far of the subjective symptoms. It is present in varying 
degrees in a large number of disorders, and is variously de- 
scribed and likened to familiar sensations by patients. The 
sensation of formication, as though insects were crawling over 
the surface, may be mentioned as one of the most striking 
varieties. 



ETIOLOGY. 

The causes at work in the production of the various dis- 
eases which affect the skin are manifold. In order thor- 
oughly to comprehend them it is of the utmost importance 
that an expansive view of the subject be taken, for in many 
instances it will be found that the manifestations upon the 
surface are but indices of disorder in other portions of the 
system. 

A large proportion of the cutaneous diseases are intimately 
associated with derangement of the internal economy, and are, 
therefore, strictly speaking, symptomatic diseases. As striking 
examples of such complaints, the polymorphous erythemata, 
purpura, and certain of the inflammatory affections, may be 
cited. 

On the other hand, a great number of diseases have their 
origin in the skin itself, and are confined iu their action 
to this organ alone ; these are the so-called idiopathic dis- 
orders. To this class belong all of the local diseases, as, for 
example, certain of the hypertrophies and atrophies, as well 
as those numerous conditions produced by external agencies, 
including parasites. 

It must never be lost sight of, however, that the relation- 
ship between the system at large and the skin is extremely 
close, so much so that very frequently it becomes a most 
difficult matter to determine to what extent a disease is 
local or constitutional. The line of demarcation cannot be 
a strict one. 

The subject of etiology may be considered under the three 
following heads : conditions influencing disease, internal 
causes, and external causes. 

55 



;,,; ETIOLOGY. 

CONDITIONS INFLUENCING DISEASE. 

Age.— It is well known that a large number of diseases are 
apt to make their appearance at certain periods of life, while 
others may appear at any time. A limited number are noted 
to occur only at stated ages, thus manifesting a striking pe- 
culiarity. Ichthyosis first shows itself during early child- 
hood, commonly at about the second year. The congenital 
svphilodermata appear, as a rule, between the first and third 
months of life; at times they are present at birth. Tinea 
tonsurans is a disease of childhood; it is extremely rare in 
the adult. Impetigo contagiosa is likewise almost exclusively 
confined in its origin to the early years of life. Tinea versi- 
color, on the other hand, is never seen in children. The 
parasitic diseases in general rarely occur in the old; they 
are met with from infancy to middle age. Phtheiriasis of 
the body is but seldom observed in the child. 

Carcinoma never occurs in the young; it rarely manifests 
itself before middle age, and frequently not until old age. 
Pruritus is, in the majority of cases, an affection of adult 
life. 

Sex. — It will be found that certain diseases are to a great 
extent peculiar to one or the other sex, while not a few are 
noted to be much more common in one than in the other. For 
example, sycosis is met with only in the male; epithelioma 
is of more frequent occurrence in the male ; while lupus 
is more common in the female. 

Seasons. — The seasons exert a very marked influence upon 
many of the inflammatory affections, as well as upon those 
of other classes; the majority of diseases are aggravated by 
cold weather, as is commonly observed in eczema, psori- 
asis, and ichthyosis. Pruritus hiemalis is encountered only 
during cold weather. Other disorders, again, occur only 
during the hot months, as, for instance, prickly heat; while 
still others are peculiar to the spring and autumn seasons, 
as herpes iris. 

Climate.— The influence of climate in the production of 
cutaneous disease cannot, I think, be questioned. Obser- 
vations have established the fact that certain diseases are 



ETIOLOGY. 57 

almost peculiar to certain countries ; as examples, leprosy, 
elephantiasis Arabum, frambcesia, and pellagra may be 
mentioned. To what extent, however, climate alone is to 
be held accountable cannot be definitely ascertained; other 
agencies, as hygiene, diet, and the habits of the people, 
must also receive consideration as probably having a share 
in the causation of the malady. 

INTERNAL CAUSES. 

Here are to be classed all those causes originating in- 
ternally, of a constitutional nature, which are known to be 
able in any way, however remote, to give rise to disease 
of the skin. They are numerous and call for the most pro- 
found investigation. At times they are very obscure and far 
removed in their seat from the skin ; in other cases they are 
so commonplace as to be overlooked by the casual observer. 

Hereditability. — Certain diseases are known to be heredi- 
tary, handed down from parent to child; as common ex- 
amples, syphilis, leprosy, ichthyosis, psoriasis, and eczema 
may be cited. It must not, however, be supposed that these 
diseases are in every instance hereditary; for, according to 
my experience, the two latter affections are more frequently 
found to be developed in the individual tie novo than to be 
transmitted from parents. 

Predisposition. — By this term I mean a peculiar, inherent 
state of the constitution, which inclines to the ready devel- 
opment of one or another disease. Its existence is not un- 
common. The tendency may exhibit itself in one, or, as is 
more apt to be the case, in all of the members of a family. It 
may be inherited or it may originate with the individual. 
Thus, it is a matter of every-day observation that certain 
families manifest more or less of a disposition to the devel- 
opment, under favorable conditions, of some of the com- 
moner forms of disease, especially those of an inflammatory 
character. 

Constitutional Diseases. — These in many instances exert a 
potent influence upon the skin. At times the constitutional 
malady is of such a nature that its existence merely predis- 
poses to disorder of the skin, as is the case, for example, in 



58 ETIOLOGY. 

chlorosis; while in other instances, as in the acute exan- 
themata, and in syphilis, it is of so violent a nature that the 
eruption is but one of a number of prominent and constant 
symptoms. In this connection it may be observed that gen- 
eral ill health, resulting from a variety of causes, plays quite 
a conspicuous part in both the causation and the continuance 
of cutaneous affections; recognition of this fact will fre- 
quently be of assistance as a guide in the treatment. It is 
owing to a deterioration in the normal state of health of the 
individual that furunculi, ecthyma, cachectic acne, and ill- 
conditioned excoriations often show themselves. 

Disorders of Internal Organs. — Here may be mentioned a 
number of functional and organic disorders capable, under 
'peculiar conditions, of causing marked cutaneous manifesta- 
tions. 

Derangement of the alimentary canal is, in my opinion, a 
prolific source of a large number of diseases, among which 
eczema, urticaria, and acne stand forth as prominent ex- 
amples. 

Affections of the kidney occasionally give rise to pruri- 
tus, and, more rarely, to eczema. Disorders of the liver 
are known to occasion pigment discolorations, as well as in- 
directly other affections. 

Uterine diseases are likewise recognized as frequently 
causing pigmentary disturbances, urticaria, eczema, and 
other troubles. 

Derangement of the nervous system is capable of giving 
rise to a variety of disorders; eczema, herpes, urticaria, 
pruritus, and alopecia may be referred to as being not in- 
frequently caused and influenced by both functional and 
organic disease of the nervous structures. 

Food.— Diet is accountable for a multitude of diseases. 
Improper quantity of food, whether too much or too little, 
and unsuitable quality, are both to be regarded as conspicu- 
ous factors in the causation of diseases often of the most 
diverse nature. To keep the economy in a perfect state of 
equilibrium it is positively essential that the proper amount 
and kind of nutriment be taken into the system. I firmly 
believe that more diseases of the skin arise from improper 



ETIOLOGY. 59 

diet than from any other single cause; in proof of this, one 
, has hut to glance at the clinics of our great hospitals and 
dispensaries, and to note the general health and condition 
of the victims of these disorders. 

Certain kinds of diet are particularly liable to occasion 
cutaneous disturbance; the ingestion offish, especially shell- 
fish, in many individuals is sufficient to call forth urticaria. 
Certain fruits, strawberries, raspberries, are in like manner 
at times followed by urticaria. Oatmeal and buckwheat are 
also known to occasion pruritus. 

The injurious effects of wine, beer, indigestible articles of 
food, as cheese, pickles, spices, pastry, and the like, are fre- 
quently seen in eczema, urticaria, acne, and other diseases. 
The cause here is an exciting one, and indirect as regards 
f the skin, but is not on this account any the less distinctive in 
its results. 

Great latitude is to be granted in the consideration of 
this subject; for, what proves poison to one is food for 
another. 

Medicine. — The ingestion of certain drugs, used as medi- 
cines, is at times productive of mischief upon the skin ; 
i striking instances are observed in the urticarial eruption 
1 occasionally following the administration of copaiba or of 
cubebs. 

The bromide and iodide of potassium are also known to 
produce peculiar forms of eruption. 

Pregnancy. — This state is not infrequently noted to exert 
a decided influence upon the skin. JSTow and then it is 
observed to be the origin of attacks of eczema, herpes, and 
pruritus, which disappear immediately and spontaneously 
upon the removal of the cause. On the other hand, chronic 
affections, as eczema and psoriasis, are often observed to be 
very much better during this period. 

Dentition. — This process, it seems to me, is to be regarded 
merely as one of the exciting causes of cutaneous disorder; 
its importance, viewed in the light of a cause of disease, is 
altogether secondary, and should not be over-estimated. 

Vaccination. — In addition to the usual local disturbance 
which this process occasions, it is now and then followed by 






50 ETIOLOGY. 

peculiar erythematous and pustular affections; they occur, 
however, only rarely, and are benign in their nature. 

EXTERNAL CAUSES. 

The causes of this nature are numerous. Many of them 
are to be viewed simply as exciting causes, giving rise to 
trouble only under peculiar conditions, or in those cases 
where there already exists a predisposition to the disease 
which manifests itself. Others, however, act injuriously 
upon the skin, and are the direct source of disease. 

Occupation. — Certain occupations are known to be pro- 
ductive of harm to the skin, giving rise to hyperemia, in- 
flammation, or hypertrophy. 

Workers in chemicals and dye-stuffs, arsenic, etc., are 
exceedingly liable to suffer from the irritating substances 
with which they are obliged to come in contact. Washer- 
women exposed to the long-continued influence of water 
and soap, and masons, may also be referred to ; individuals 
following these occupations are not infrequently the victims 
of harsh skin and extensive fissures. 

Machinists, carpenters, shoemakers, and others who make 
constant use of tools, are ordinarily the subjects of more or 
less epithelial hypertrophy, in the form of callosities. 

The extremes of heat and cold also act as causes in the 
production of disease ; as examples of the former, erythema 
and dermatitis, resulting from continued exposure to a high 
temperature, may be mentioned. The action of the sun 
in calling forth several varieties of disease is well known. 
Cold acts in a somewhat similar manner, as observed in 
frost-bite. 

Clothing. — Certain articles of clothing, as well as certain 
modes of dress, must also be regarded as giving rise to irri 
tation and hyperemia of the skin. The rough flannel worn 
so persistently by the working classes, not infrequently acts 
as an exciting cause of erythema. Constant friction produced 
by ill-fitting articles of wear over tender portions of the body, 
as a stocking, or shoe, over the instep or about the heel, will! 
often suffice to give rise to excoriations, ulcers, and other 
forms of disease. 



ETIOLOGY. 61 

Irritants. — Cutaneous irritants are the source of much mis- 
chief; the too free use of certain external remedies may 
prove causes of hyperemia and inflammation. Among these, 
as most frequently occasioning trouble, sulphur, croton oil, 
the preparations of mercury, caustics in general, rubefa- 
cients, tincture of arnica, and the various parasiticides, may 
be mentioned. 

Uncleanliness. — Uncleanliness, the presence of foreign mat- 
ter upon the surface, must likewise be considered as an ex- 
citing cause of disease; tinea favosa is found to flourish only 
upon those who are negligent of their person. On the other 
hand, too much attention to cleanliness may also be followed 
by an abnormal condition of the skin ; too frequent bathing 
and the constant use of strong soaps are hurtful to the epi- 
dermis. 

Scratching. — This operation brings about material and often 
extensive lesions upon the surface, especially in affections of 
an inflammatory and pruriginous character. It is noted, how- 
ever, to produce serious trouble only in those cases in which 
the skin has already become more or less altered by disease. 
Thus, while in scabies, phtheiriasis, eczema, and ecthyma, 
scratching creates a large amount of local disturbance, greatly 
complicating the primary disease, it cannot be regarded as 
fruitful of the same amount of harm upon perfectly sound 
skin. In the disorders referred to it is, when protracted, 
the cause of structural changes in the skin, as manifested 
by excoriations, pigment alterations, and thickening. 

Contagion. — Among the external causes the most important 
remains to be spoken of under this head. 

The varieties of contagion are not numerous; they are 
nevertheless exceedingly prolific sources of disease. Among 
the infectious diseases, those w T hich are communicable 
through the medium of the atmosphere, small-pox, measles, 
scarlatina, and erysipelas occupy the most conspicuous 
place ; while • the contagious affections, strictly speaking, 
those which are transmissible only through direct contact, 
comprise syphilis, contagious impetigo, vaccinia, certain low 
forms of specific inflammation, as equinia or glanders, and 
the parasites. Many of the cutaneous lesions of syphilis 



C2 ETIOLOGY. 

are contagions, and are active agents in the spread of this 
common malady. The disorders occasioned by the animal 
and vegetable parasites of the skin form a distinct group. 
They are all contagious, although not equally so, some being 
at all times readily communicable, while others manifest 
their contagious properties only under certain conditions. 
All individuals, for example, are not to the same extent 
susceptible to the influence of the vegetable parasites; two 
persons may, under like circumstances, be exposed to the 
same parasite, only one of whom will, in all probability, 
contract the affection. I am convinced that in the case of 
these parasites, a peculiar condition of the skin is quite as 
essential to the development of the disease as the presence 
of the fungus itself. 

To the group of animal parasites belong the itch mite, 
head louse, body louse, and crab louse, together with several 
other insects of less importance, as the flea, which under 
favorable circumstances commit depredations upon the skin. 
The vegetable parasites, microscopic fungi, are termed the 
achorion Schonleinii, tricophyton, and microsporon furfur. 



PATHOLOGY. 

The pathology of the skin is to be studied in the same 
light as that of other parts of the economy. The skin differs 
from other membranes only in its anatomy, which, being 
complex, is subject to a variety of alterations, some of which 
are peculiar to this organ. It is liable to the same patho- 
logical changes, as, for example, hyperemia, inflammation, 
hypertrophy, etc., as take place in other organs, and conse- 
quently is to be regarded from the standpoint of general 
pathology. 

T.;e morbid changes which occur in the skin are numer- 
ous, and are, moreover, liable to varied modifications. To 
comprehend them corrf tly, a thorough knowledge of the 
normal structures is absolutely essential. All portions of the 
integument, either separately or together, may be involved 
by disease ; it is found, however, that certain parts are more 
frequently invaded than others. 

The epidermis, partly in consequence of its serving as the 
external covering of the body, and therefore liable to a great 
variety of influences, and also because it is so intimately 
associated with the deeper and more important parts, is very 
commonly the seat of extensive alteration. From its position 
it necessarily assumes a more or less prominent part in the 
pathology of all cutaneous manifestations. Even in those 
instances in which the pathological process is situated exclu- 
sively in the deeper structures, it is noted to show morbid 
changes, as desquamation, atrophy, etc., the result of im- 
paired nutrition in the deeper layers. It is a not uncommon 
seat of hypertrophy, as seen in callosity and like affections. 
The vegetable parasites also have their habitat here, not in- 
frequently taking complete possession of its outer or horny 

63 



,;| PATHOLOGY. 

layer. The delicate rete mucosum, owing to its close prox- 
imity to the corium, and the relations which it bears to this 
structure, is a very frequent seat of disease; it is seriously 
involved in all of the exudative affections, eczema, herpes, 
psoriasis, etc., as well as, to a greater or less extent, in 
numerous other diseases. 

In the corium, however, occur by far the greater number 
of morbid processes. The peculiar structure of this tissue, 
consisting of a network of connective tissue, extensive plex- 
uses of bloodvessels, lymphatics, nerves, and a complete 
system of glandular apparatus, renders it particularly liable 
to disorder. It is, moreover, through certain organs which 
have their seat in this tissue, for example, the sudoriparous 
glands, that numerous effete products of the econonry find 
their exit, some of which give rise to more or less cutaneous 
disturbance. 

Hyperemias all have their seat in the corium ; likewise 
that great class of diseases, the exudations. Hemorrhages 
also occur here, as in purpura. Hypertrophies, scleroderma, 
for example, atrophies, new growths of various kinds, all 
invade the corium. Parasites, especially the itch mite, the 
louse, and similar insects, also prey upon this tissue. 

It is in the true skin that certain structural changes of the 
bloodvessels, lymphatics, and nerves take place, as found in 
angioma, lymphangioma, and neuroma. Functional disturb- 
ances of the nervous system, the so-called neuroses, likewise 
here manifest themselves. 

Both the sebiparous and sudoriparous glandular systems 
are attacked by functional disorders, as in seborrhcea and 
in hyperidrosis; both may also be the seat of structural 
change, either alone, as in molluscum sebaceum, or in con- 
nection with disease of other tissues, as in lupus erythema- 
tosus. 

The hair and nail are also invaded by pathological pro- 
cesses, either idiopathically, as in tinea tonsurans, tinea 
favosa, and simple hypertrophy, or symptomatically, as in 
alopecia, eczema, and psoriasis. 

Hyperaemia. — Cutaneous hyperemia consists in an excess- 



PATHOLOGY. 65 

ive amount of blood in the capillaries of the skin. It is for 
the most part an ephemeral condition, lasting but a short 
time, after which the surplus blood returns to its accustomed 
channels, leaving the skin in its normal state. The seat of 
the disorder is in the superficial strata of the skin, either in 
the papillary or deeper layers of the corium. As a rule, it is 
not followed by desquamation or pigmentation; when these 
symptoms occur, it is a sign that some slight exudation has. 
taken place. Instead of terminating in this manner, how- 
ever, hyperemia may readily pass on into inflammation. 
When inflammation occurs, it is always preceded by hyper- 
emia. Hyperemia may exist alone, running its course 
and ending as. such, but inflammation cannot exist without 
having been preceded by hyperemia. Hyperemia may arise 
from numerous causes, some of them quite different in kind, 
as, for example, heat, cold, and systemic disorder. 

The hyperemias possess certain characteristic features. 
Their existence is always marked by redness of the skin, 
varying in shade and tint from pink to dark red. The red- 
ness is superficial in character, disappears altogether under 
pressure, but is observed to return instantly. The tempera- 
ture of the skin is frequently elevated ; at times it is felt to 
be markedly so. 

The presence of hyperemia gives rise to a variety of 
external forms or markings upon the surface; usually they 
are without definite outline. 

Hyperemias are ordinarily acute; they may last minutes, 
hours, or even days. Slight burning sensations occasionally 
accompany them. 

Anaemia. — Directly the reverse of hyperemia is the con- 
dition termed anemia, in which there is a deficiency in the 
amount of blood in the cutaneous capillaries. 

This state may result from an absolute want of blood in 
the general system in consequence of hemorrhage, or it may 
follow disease, as in chlorosis. It is characterized by loss 
of the natural color of the skin, succeeded by a blanched, 
whitish or yellow hue, affecting, according to its cause and 
nature, either the whole surface or certain regions, as the 
extremities. It is also attended by a decrease in the temper- 

5 



00 PATHOLOGY. 

ature of the surface, and at times by cold sweating. Anaemia 
dues not give rise to substantive diseases of the skin, and 
therefore is of little importance to the dermatologist. 

Inflammation. — By this term is understood a pathological 

process characterized by changes in the circulation and blood- 

els, the exudation of liquor sanguinis and both white and 

red corpuscles, attended by the symptoms of redness, .heat, 

swelling, and more or less pain. 

The changes which take place, with special reference to 
the skin, may be briefly summed up as follows. Hyper- 
emia invariably precedes the process. After this condition 
has existed for a longer or shorter period, the first observa- 
ble alteration in the tissues, as seen under the microscope, 
consists in dilatation of the minute arterial vessels, fol- 
lowed by the same change in the venous circulation. It is 
found that during the commencement of the inflammatory 
process the blood flows through the vessels more rapidly 
than normal, while later this acceleration is followed by a 
marked retardation in the pace of the current, unaccompa- 
nied by contraction in the calibre of the vessels. The blood 
corpuscles now begin to accumulate in the vessels, which 
soon become filled, whereupon a condition of stasis occurs. 
At this stage the white corpuscles are observed to adhere 
to the sides of the vessels, and to show increased activity of 
movement, whereby those adjacent to the walls gradually 
imbed themselves in the coats of the artery or vein, and 
thus, working themselves through, find their way into the 
tissues without. The red corpuscles in the same way, though 
in less numbers, also pass through the walls of the vessels. 
The liquor sanguiuis is in like manner freely exuded through 
the vessels, in varying quantity. The process may be either 
acute or chronic in its course, its duration depending upon 
the nature of the cause and the continuance of the same in 
relation to the affected part. It may terminate either in 
resorption, suppuration, or hypertrophy. 

The product of inflammation, that which results from the 
exudation of the liquor sanguinis and the corpuscles, consists 
either of a fluid, semi-fluid, or of a formed cellular material; 






PATHOLOGY. 67 

not infrequently several of these products are at the same time 
present. Fluid exudation is composed of a serous, yellow- 
ish, gummy, albuminous liquid, containing usually a limited 
number of blood corpuscles, especially the white. The con- 
stituency of the exudation, particularly as to the amount of 
cellular material, corpuscles and cells, varies with the dis- 
ease. Typical fluid exudation is observed in vesiculation, as, 
for example, in the vesicles of eczema and herpes; occurring 
in a less pronounced manner, it gives rise to swelling, 
oedema, and infiltration, which may be either circumscribed 
or diffused, as in stages of multiform erythema and in ery- 
sipelas. 

Instead of a fluid the product of exudation may consist of 
formed elements, cells, unaccompanied to any extent by the. 
escape of fluid, in which event it is firm or plastic ; it may 
be circumscribed or diffused. Its presence in the skin is 
manifested by solid formations and infiltrations, examples of 
which are seen in certain inflammatory papulae, patches of 
thickening, etc. 

In the process of pustulation, as in the pustule of ec- 
thyma, is seen another form of exudation, characterized by 
the abundant presence of cellular material, pus corpuscles, 
suspended in simple fluid exudation. 

The lines of demarcation which separate the varieties of 
exudation are by no means sharp; for, as seen clinically, all 
degrees of difference exist between the typical fluid, suppu- 
rative, and plastic varieties. Very commonly they pass from 
one to the other by gradual stages, or, their course may be 
arrested at any stage of their existence. Thus, if certain of 
the exudative diseases, erythema multiforme and eczema, for 
example, be studied, a great variety of stages of exudation 
may often be observed, giving rise to the papule, papulo- 
vesicle, vesicle, vesico-pustule, and pustule. 

Viewed in this light, a number of cutaneous lesions result 
as the product of exudation, which either run a definite 
course or are subject to modification. 

The product of exudation may have its chief seat in any 
of the various parts which compose the integument. Fluid 
exudation commonly seeks its outlet about the upper strata 



(jy PATHOLOGY. 

of the corium and between the papillary layer and the epi- 
dermis, occasioning vesicles, blebs, and pustules; or, taking 
place in the deeper structures, it assumes the form of a 
Beroua infiltration, marked by oedema and swelling of the 
whole skin. Plastic exudation is usually found to have its 
seat in the corium and deeper layers, as seen in papules, 
tubercles, and similarly formed lesions. 

The product of exudation may disappear by the process of 
absorption, as occurs in urticaria and in many other diseases, 
or, it may pass on in its course and end in suppuration, as, 
for example, in furuncle. 

Hemorrhage. — Cutaneous hemorrhage consists in the ex- 
travasation of blood from the vessels into the surrounding 
tissues, the result either of diapedesis — the passage of the 
fluid through the walls of the vessels without rupture — or of 
rupture of the capillaries. It takes place in the skin in the 
same manner as in the other tissues of the body. The lesions 
consist of variously sized, more or less circumscribed, aggre- 
gations of blood, having their seat in the corium and sub- 
cutaneous tissues. They possess certain features by which 
they may always be recognized. 

They make their appearance suddenly. Having once as- 
sumed a definite size and form, they usually retain it, until, 
by the gradual process of absorption, they fade away and 
finally disappear. 

They always present a reddish color, varying in shade 
from light to dark, according to their nature, location, ex- 
tent, and the length of time they have existed. In addition 
to the reddish color, they commonly exhibit, particularly 
about the period of their decline, more or less pronounced 
yellowish, bluish, and greenish hues. These variations are 
due to the changes which the coloring matter of the blood 
undergoes during absorption. 

The products of cutaneous hemorrhage are peculiar in that 
they do not disappear under pressure. They are usually upon 
a level with the surrounding skin; occasionally they become 
somewhat elevated in the form of papules and tumors; this, 
however, rarely takes place excepting in very extensive 
extravasations, or in those cases in which the hemorrhage 



PATHOLOGY. 69 

accompanies other lesions as a secondary symptom, as in 
hemorrhagic variola. They disappear slowly by absorption, 
leaving pigmentation of the skin. 

Hypertrophy. — By hypertrophy is meant an increase in the 
amount of a tissue which already exists. It may take place 
in two ways ; either by an increased growth of the already 
existing elements, or by the formation of new elements of 
the same tissue. The component parts of the integument 
are all subject to hypertrophy, the process either confining 
itself to one structure, as, for example, the epidermis, or 
involving several or all of the parts at the same time. 

Typical hypertrophy of the epidermis occurs in callosities. 
In ichthyosis, corns, horns, and warts it involves both the 
epidermis and the papillary layer of the corium. 

Simple increase of the normal coloring matter of the skin 
is seen in lentigo and chloasma. Hypertrophy of the con- 
nective tissue is noted in scleroderma; while in elephantiasis 
Arabum extensive augmentation occurs in all the cutaneous 
and subcutaneous structures. The hair and nail are also 
subject to hypertrophy. 

Atrophy. — Here the process is exactly the reverse of hyper- 
trophy. It is characterized by a decrease in either the size 
or the number of the histological elements which go to make 
up the structure. When the size alone of the elements is 
diminished, the condition is termed simple atrophy ; when 
their number is lesseued, it is called numerical atropliy. It 
may be either general, affecting the whole surface, as in 
senile atrophy, or partial, involving a certain region, as in 
alopecia. All parts of the integument are liable to undergo 
atrophy. In vitiligo, both marked atrophy and hypertrophy 
of the normal pigment of the skin go on together. Senile 
atrophy may be taken as the typical representation of general 
atrophy of the cutaneous structures. The hair, as in canities 
and alopecia, in which diseases both the pigment and the 
structure of the hair itself are involved, is one of the most 
frequent seats of the process. The nail, at times, also suffers. 

Atrophy is usually characterized by diminution in size. 
It may either manifest itself as a simple reduction in size of 
the part affected, without structural change, or it may result 



;.) PATHOLOGY. 

in a degeneration, as in morphcea, in which event the tissues 
undergo change, a new structure, different from the normal 
elements of the part, coming into existence. 

Atrophy, succinctly stated, is want of balance between the 
nutritive supply and the part to be nourished. 

New Growths.— New growths consist in the development of 
tissue which is new or foreign to the structure in which it 
occurs. 

Various new growths or new formations are found in the 
skin, composed of tissue either similar to that of which the 
part is constituted, as, for example, connective tissue, or 
of a formation of an entirely different character, as cellular 
material. 

The connective-tissue new growths find their expression 
in keloid, fibrous molluscum, xanthoma, and in scars. Cel- 
lular new formations, a most important pathological group, 
consist of deposits or infiltrations of cell elements foreign to 
the normal tissues; here are found lupus vulgaris, lupus 
erythematosus, rhinoscleroma, elephantiasis Grsecorum, car- 
cinoma, and syphilis. 

Bloodvessels and lymphatics are also the seat of new 
growths, as seen in angioma and lymphangioma of the skin. 

Clinically, new growths are either benign or malignant. 

Parasites. — Parasites of the skin are those animal and 
vegetable organisms which, under favorable circumstances, 
prey upon the cutaneous tissues. They are divided into the 
vegetable or fungous, and the animal. 

Vegetable parasites consist of minute, microscopic plants, 
which under certain conditions attach themselves to the sur- 
face of the skin and there vegetate. They inhabit chiefly 
the horny layer of the epidermis, although they may pene- 
trate even deeper, as into the follicles, and thus invade more 
tender structures. The hair and nail are also attacked by 
these growths, as seen in tinea favosa. 

Three varieties of fungus are known to invade the skin, 
each producing disease having distinctive clinical and patho- 
logical features. They are the achorion Schonleinii, the 
fungus of tinea favosa ; the trichophyton, giving rise to three 
affections, namely, tinea circinata, tinea tonsurans, and tinea 






PATHOLOGY. 71 

sycosis ; and the microsporon furfur, the parasite of tinea 
versicolor. 

These three fungi are similar in structure, and are made 
up of mycelium and spores. 

They all act as irritants to the skin. 

The amount of disturbance which their presence exercises 
varies with the parasite and the region attacked. They may 
be productive of hyperemia only, as in tinea versicolor, or 
they may prove so irritating as to occasion extensive exuda- 
tion, as in tinea sycosis. 

The group of animal parasites comprise a number of in- 
sects, chief among which are the acarus scabiei or itch mite, 
and the pediculus or louse. The acarus folliculorum, an 
exceedingly minute, inoffensive inhabitant of the sebaceous 
follicles, may also be here mentioned. Besides these there 
are others, as the leptus autumnalis, pulex irritans or common 
ilea, cimex lectularius or common bed-bug, pulex penetrans 
or sand-flea, tilaria medinensis or Guinea-w^orm, and certain 
varieties of flies. These insects, with the exception of the 
acarus folliculorum, all occasion various lesions upon the 
skin, which are either of an exudative or a hemorrhagic 
nature. The ravages of the itch mite give rise to inflamma- 
tory lesions, similar to those of vesicular and pustular eczema. 
The bites of the pediculus, flea, and bed-bug produce minute 
hemorrhages. 



DIAGNOSIS. 

If satisfactory results are to be obtained in the treatment 
of cutaneous diseases, it is of the utmost importance that the 
physician know definitely what affection he has before him. 
Without a full comprehension of the disorder, and the course 
it is likely to pursue, all treatment must be empirical .and 
attended only with hap-hazard results. With the assistance, 
however, of a method for the examination of cases, and an 
understanding of the numerous signs and symptoms encoun- 
tered, there should remain little difficulty in the recognition 
of the diseases. One requisite is indispensable to success 
in diagnosis, — the power of close observation and scrutiny, 
without which the student will acquire but a superficial and 
unsatisfactory knowledge of the subject. 






Light. — To examine a case properly, the first point to be 
secured is proper light. Daylight is an essential, for arti- 
ficial light, as from a lamp or from gas, is necessarily more 
or less colored, and gives to the skin an unnatural tint, by 
which it is easy to commit an error. A good white light is 
the best ; under its influence we obtain a more correct idea 
of the color of the eruption, — always an important point, and 
one upon which alone may depend our decision. Various 
signs of value and interest frequently come to notice under a 
good light which might pass unperceived with an uncertain 
illumination; thus, a patch of tinea versicolor might readily 
escape detection with an imperfect light 

Temperature of the Apartment. — A moderately warm room 

should be provided. The patient, whether in bed or about, 

will of necessity be somewhat exposed to the air during the 

examination; sufficient warmth is important both for his 
72 



DIAGNOSIS. 73 

comfort and to preserve the ordinary temperature of the 
skin. 

Inspection. — The patient will generally direct our attention 
to a certain part of the disease, usually that portion which 
causes him the most annoyance. The portion offered for 
inspection should be slowly and attentively examined, and, 
perhaps, at the same time, a few simple questions asked, with 
a view to gaining the confidence of our new patient. The 
physician should endeavor to obtain this as soon as possible 
in the course of the examination ; in women it must not be 
forgotten that a feeling of more or less diffidence always 
exists when called upon to expose to a stranger even a por- 
tion of their person, and that to overcome this, full confidence 
must be enjoyed. It may now be asked what other parts of 
the body are involved, and to what extent ; thus by carefully 
and judiciously placed questions it will be ascertained exactly 
what regions are affected. If the disease be diffused, the 
various parts should be inspected one by one. If the case 
be that of a man or child, it is desirable to examine the whole 
body at the same time, in order that nothing escape obser- 
vation. This proceeding is the more important as the disease 
manifests a tendency to be scattered over the body, for, as I 
shall show presently, much is to be learned from the general 
features of the eruption. 

Examination to be thorough. — The examination during the 
first interview should be a complete and careful one, for it 
may so happen that by the second visit the eruption will 
have undergone great change, and, indeed, have lost in a 
great measure its characteristic features. Cases should always 
be investigated at the time they first come under notice ; in 
order to know a disease well, it is essential to be familiar 
with all its phases, and hence every change in appearance is 
to be recorded for future reference. 

The general color of the skin should be noted, in order to 
determine its vascularity and general vitality. It should be 
felt, in order to ascertain its temperature, whether increased 
or diminished. In rosacea of the nose, for example, the skin 
has the appearance of being hot and inflamed, when touch 
often actually reveals a sense of cold. Its softness or harsh- 



74 DIAGNOSIS. 

should also be ascertained. Certain diseases may be j 
diagnosed by tbe sense of touch alone, as, for instance, 
ichthyosis, where its peculiar harshness is characteristic to 
an educated hand. It should be asked whether the patient I 
is in the habit of bathing, whether in warm or cold water, 1 
and how often. Baths influence the skin, and especially an I 
eruptioD, in a marked manner. 

It should be noted whether the body is fat or lean; to 
what extent the cutaneous structures are nourished. The 
condition of the hair follicles and sebaceous gland ducts 
should be observed, whether free and open, or plugged up; 
the epidermis, whether dry and desquamative, or normal ; j 
the secretion of sweat, if scanty or profuse. In order to de- J 
terniine these points, the finger or hand may be passed over | 
the surface, when their presence or absence will be quickly J 
recognized. 

Constitutional Disturbance. — In the majority of the diseases 
of the skin no perceptible constitutional disturbance exists, * 
but there are, however, a certain number of instances where } 
marked systemic derangement, as shown by fever, malaise, 
headache, constipation, coated tongue, is always present at 
some time or other during the course. Symptoms of this 
character should be looked for, and carefully noted when 
present, for they prove valuable in enabling us to decide 
between affections which resemble one another in external 
form. The exanthemata, for instance, are always accom- 
panied by symptoms of general disturbance, and in their 
early stages, at times, it is this alone which permits us to 
diagnose them from other troubles which they simulate upon 
the skin. 

Age.— The age of the patient is to be taken into consider 
ation; whether an infant, a child, an adult, or an old person. 
We know that certain diseases occur almost exclusively at 
certain periods of life ; that certain affections are found onl 
in adult life, and that others are common only to infan 
We know, moreover, that infants and young children a 
exempt from certain diseases ; in questions of diagnosis thes 
can at once be excluded from the list. For example, psoriasi 
one of the most frequent diseases in adult life, is not fou 



DIAGNOSIS. 75 

in young children ; we need not entertain its occurrence be- 
fore the sixth year, and usually it does not show itself until 
the tenth or fifteenth year. Epithelioma never occurs in 
early life; it is seen now and then at the age of twenty or 
thirty, but is not common before fifty. 

Sex. — The sex of the patient must likewise be taken into 
account, for males are more liable to certain affections than 
females, and vice versa. It is also to be borne in mind 
that, owing to peculiarities in the anatomy of one sex or the 
other, certain diseases are found in the one which have no 
existence in the other, as sycosis, a disease found only in the 
male. 

Temperament. — The temperament or natural general organ- 
ization of the patient should be noticed; whether the com- 
plexion be light and florid or heavy and dark in color, etc. 
It is well recognized that certain forms of disease are prone 
to come upon those whose constitutions are of a particular 
type. Diseases of the sebaceous glands, as acne and sebor- 
rhea, are much more common upon those of the florid type. 
Eczema likewise occurs much oftener, and is more obstinate 
iu character, in those of light complexion ; the same may be 
said of psoriasis. 

Habits. — The usual habit of the patient must be inquired 
into, and his ordinary condition of health, apart from his 
cutaneous trouble, ascertained. The state of the alimentary 
canal, a region so often the seat of derangement in diseases 
of the skin, must be most searchingly investigated; not 
merely whether the patient suffers from dyspepsia or con- 
stipation, for questions of this kind are rarely sufficiently 
definite to elicit the true condition. Each part of the digest- 
ive tract should be gone over in turn, with leading ques- 
tions, assuming, for the most part, that some functional 
trouble does exist. Here, in the alimentary canal, we may 
find the key which will disclose the cause of a great number 
of skin diseases. Let the examination, then, in this direc- 
tion be scrutinizingly conducted. Permit no point, however 
slight in character, to be passed over lightly, for upon it may 
depend the exciting cause of the disease before us. 

The tongue should always be inspected, and its condition, 



76 DIAGNOSIS. 

if whitish, furred, thickened, moist, dry, or cracked, noted. 
At the same time inquiry into the usual state of the breath 
should be made; whether heavy, offensive, or feverish; if 
impure, the cause should be sought for; frequently it will 
be found associated with digestive difficulties. 

Attention should next be directed to the stomach ; and 
here we must question our patient closely, asking him 
whether he is subject to eructations, flatulence, acidity of 
stomach, or indigestion, or, if the case demand it, using the 
more popular terms of heart-burn and water-brash. Persons 
are not infrequently encountered who positively deny all 
knowledge of any dyspepsia or indigestion, but who eagerly 
admit suffering from heart-burn ! In this connection the 
quality and quantity of food taken may be inquired into, 
ascertaining whether the indigestion, for example, is due 
simply to certain articles of food, or to other causes. The 
state of the bowels must be investigated, whether normal, 
temporarily or habitually constipated, or whether irregular 
in their action. 

In many cases it is of importance to make an examination 
of the urine, a procedure which is always in place in the 
investigation of any serious disease whatsoever. 

Occupation. — The occupation of the patient frequently af- 
fords a clue to the cause of the disease. It should always 
be ascertained. It is well known that various kinds of work 
play a part in the production and continuance of certain 
forms of disease. An affection, trivial in character, may 
be greatly aggravated by exposure to irritating substances. 
For example, a very slight eczema upon a washerwoman's 
hand may be much increased by continued work; ultimately 
a severe eczema rubrum of the whole arm may result, 
she persist in her occupation, the chances are that the troubh 
will continue until she is compelled, through distress, t( 
desist. Workers in the manufacture of chemicals also suffe 
at times from artificial diseases; those exposed in mercui 
and arsenic mines are subject to peculiar forms of eruptioi 
while workers in caustics, acids, iodine, bromine, tar, an< 
other similar substances, may likewise be attacked witl 
peculiar disorders of the skin. 



DIAGNOSIS. 77 

GENERAL FEATURES OF THE DISEASE. 

We now come to consider the disease itself, including the 
lesions of the skin and their peculiarities. They must be 
very attentively studied, for they afford the most accurate 
information which it is possible to obtain concerning the 
nature of the case; they offer the only knowledge, indeed, 
which can be relied upon. One .thoroughly familiar with 
the various cutaneous lesions is, as a rule, enabled to com- 
prehend the whole character of a disease. 

Acute or Chronic. — It is, in the first place, to be noted 
whether the disease is acute or chronic in its course; and, 
furthermore, to observe the stage in which it appears to 
be, whether upon the increase or upon the decline. In the 
majority of cases this can be learned by simple inspection, 
or, when this is not possible, from the statement of the 
patient. It is also important at the same time to inquire 
into the duration of the complaint, and whether it is a first 
attack or a relapse. 

Extent of Disease. — The extent of the affection may now be 
ascertained ; whether confined to a certain region, or occur- 
ring in various portions of the body. 

The regions involved should be observed, for it is well 
known that some diseases have a predilection for certain 
parts of the body, as seen in seborrhcea, acne, etc. Other dis- 
eases are encountered only in certain localities; for example, 
sycosis. 

Distribution. — The distribution of the eruption may often 
serve as an aid in diagnosis; as the configuration or shape 
of the patches, and the grouping and arrangement of the 
lesions. 

Color. — The general color of the disease will always throw 
considerable light upon the nature of the process, as, for in- 
stance, in the syphilitic eruptions; in certain new growths, as 
xanthoma and keloid; in chloasma; in tinea versicolor, tinea 
favosa, and in numerous other affections. 

Individual Lesions. — It is to be noted whether the individual 
lesions are of one or of several varieties; whether they are 
all in the same or in different stages of development. Their 



7S DIAGNOSIS. 






anatomical situation and number are also to be carefully 
inquired into. Finally, it is important to observe their 
evolution. 

Macules are of very frequent occurrence ; some remain as 
such throughout their entire course, as in chloasma, vitiligo, 
etc., while others, beginning as maculae, rapidly pass into 
other and more permanent lesions. 

Hypersemic affections, as the simple erythemata, discolora- 
tiona of the skin from various causes, and certain parasitic 
diseases, all present examples of maculae as their charac- 
teristic lesions. 

Fapules occur either alone or in connection with other 
structural changes. In eczema the eruption may be alto- 
gether papular, or it may be a mixture of papules and 
vesicles in various stages of development, with scales, crusts, 
etc. In the papular syphiloderm, pustules are at times seen 
intermingled with the papules. In lichen planus, prurigo, 
lichen scrofulosus, comedo, and milium, papules, possessing 
for the most part definite form, color, and structure, are 
observed. It will here be remembered that papules are of 
several varieties, some of them quite unlike in their form 
and anatomy. 

Vesicles are common, and occur in a great number of dis- 
eases. Vesicular eczema exhibits the lesion in its most 
perfect state ; it is also observed highly developed in herpes, 
miliaria, sudamina, vaccinia, and varicella. Vesico-pustules 
are seen in the so-called vesicular syphiloderm, in contagious 
impetigo, and in other affections. 

Pustules are met with in variola, pustular eczema, ec- 
thyma, acne, scabies, in the pustular syphiloderm, and in 
non-parasitic sycosis, herpes zoster, etc. Vesicles very fre- 
quently pass into pustules. 

The tubercle is often an exaggeration of the papule. It 
is seen in parasitic sycosis, acne, syphilis, carcinoma, leprosy, 
rhiuoscleroma, sarcoma, neuroma, etc. 

Tumors develop themselves in sebaceous cyst, sebaceoi: 
molluscum, fibrous molluscum, erythema nodosum, keloi 
angioma, lymphangioma, lymphadenoma, neuroma, lipom 
elephantiasis Arabum, syphilis, and in other diseases. 



DIAGNOSIS. 79 

Bullae, varying in size from a cherry to a goose-egg, are 
encountered chiefly in pemphigus, herpes iris, erysipelas, 
syphilis, and leprosy. They are also observed as the result 
of vesicants, scalds, and burns. 

Wheals are usually significant of a peculiarly sensitive 
state of the skin, which inclines to their ready formation 
upon slight provocation. They are seen most perfectly 
developed in urticaria; they also occur, more or less pro- 
nounced in character, in connection with other diseases, e.g., 
purpura. 

Scales are exceedingly common, and are observed in a 
great variety of affections; psoriasis, seborrhoea, squamous 
eczema, ichthyosis, erythematous lupus, and the vegetable 
parasitic diseases, all exhibit these products quite typically. 
Scales form to a greater or less extent in all of the exudative 
diseases; also in other classes of diseases. 

Excoriations are usually met with in those complaints 
which are accompauied by itching and like symptoms; they 
are seen chiefly in eczema, pruritus, phtheiriasis, scabies, 
and other parasitic affections. 

Fissures take place in eczema, psoriasis, and syphilis; also 
in various hypertrophies. 

Crusts are found as the product of many diseases. They 
constitute striking lesions in eczema, scabies, ecthyma, syph- 
ilis, impetigo, herpes, sycosis, leprosy, carcinoma, scrofulo- 
derma, etc. 

Ulcers take place in syphilis, lupus vulgaris, carcinoma, 
leprosy, scrofuloderma, herpes zoster, furuncle, carbuncle, 
etc. Cicatrices always follow ulceration. 



TREATMENT. 

It should always be the aim of the physician to cure the 
disease before him as rapidly and as effectually as possible; 
every known means calculated in any way to relieve the dis- 
order should be brought to bear upon the case. No fears 
need be entertained of "curing the disease too soon," or of 
" driving in the eruption," as this popular idea is variously 
expressed; the danger is rather in temporizing with the 
affection and thus permitting it to obtain the upper hand. 
It may be very safely stated that the sooner diseases of the 
skin are relieved the better both for the comfort of the suf- 
ferer and for the credit of the physician. Careful inquiry 
and extended experience show that no injurious results ever 
follow the cure of these diseases, whether this take place 
rapidly or slowly; in very many cases the time occupied in 
the treatment unfortunately extends over a long period, 
even under the most favorable circumstances, so that speedy 
recovery, when it does occur, should always be regarded 
with favor. 

lie who would be successful in the treatment of cutane- 
ous affections must first acquire a full knowledge of the 
principles of general medicine; without this groundwork 
upon which to stand, his efforts, in the majority of cases, 
will at best be rewarded by unsatisfactory results. 

Dermatology, rightly viewed, is but a department of gen- 
eral medicine; its diseases, consequently, are amenable to 
the same principles of therapeusis which hold good for dis- 
orders of other organs. A simple acute inflammation of 
the skin, for example, calls for the same general plan of 
management as an acute inflammation having its seat in 
the mucous membrane, or in other tissue of the body. The 
80 



TREATMENT. 81 

skin is but a part of the whole organization, and subject, 
therefore, to general rules of treatment. 

Before prescribing for a case there are a number of points 
which should be taken into consideration ; they may be 
referred to under the following heads : 

Previous History. — Xot infrequently the previous history of 
the patient, and more particularly of the disease itself, will 
prove of great assistance in determining upon the most suit- 
able method of treatment. 

In the first place, it is to be ascertained whether the present 
trouble is a first attack or a relapse. If the latter, the course 
of the former attack, as well as the nature of the treatment, 
should be inquired into ; whether external or internal reme- 
dies were employed, and whether they proved successful or 
otherwise. 

The preparations used should also, when practicable, be 
learned from the patient; for a knowledge of past treat- 
ment and its results may occasionally save both time and 
trouble. 

Idiosyncrasies, it must be borne in mind, are not uncom- 
mon ; hence, for example, when we are assured by a patient 
that arsenic taken internally, or tar used externally, invari- 
ably disagrees, the information enables us to be cautious as 
to the manner of prescribing these remedies. 

Present General Condition. — The general condition of the 
patient should be carefully ascertained. At a glance it is 
noted whether the patient is or is not in apparent good 
health ; whether, for example, there is a tendency to plethora 
or to anaemia; or whether chlorotic symptoms, so common 
in various diseases of the skin, are present. 

In this connection it is important to determine the pres- 
ence or absence of constitutional symptoms; whether the 
disease is strictly local or not. The appetite should be in- 
quired after; likewise the state of the alimentary canal. 
The tongue should be examined, if normal or otherwise, 
and the existence or not of dyspeptic symptoms questioned. 

The state of the bowels requires special attention ; if 
natural, irregular, or constipated in their function. The 



g2 TREATMENT. 

character of the biliary and renal secretions also calls for 
investigation. 

The condition of the nervous system should be deter- 
mined; the amount and kind of sleep enjoyed, the state of 
the mind, whether healthful or morbid, depression of spirits, 
or other like symptoms, should all be noted. 

Nature of the Disease. — Directing attention now to the skin 
itself, it is all-important to form a definite idea as to the 
nature of the process present; whether, for example, it is 
a simple hyperemia, an inflammation, or a hypertrophy. 
Recognizing the pathological process, but little difficulty is 
offered for the diagnosis. 

The duration of the disease is now ascertained; its natural 
course studied; whether localized to a small area or diffused; 
its tendency to confine itself or to spread. It is important, 
also, to determine before prescribing whether it is acute or 
chronic, and, still further, to recognize the precise stage of 
the process. 

The subjective symptoms, moreover, should be learned 
from the patient; whether pain, burning, or itching is ex- 
perienced, or whether there is complete absence of such 
symptoms. 

Cause of the Disease. — The exceeding importance of forming 
a correct opinion as to the cause which has given rise to the 
affection is so apparent as scarcely to call for more than 
mention ; upon a proper interpretation of this point will de- 
pend the success or the failure of treatment. It is only by 
treating the cause that permanent relief may be looked for. 
Too much study and investigation can scarcely be devoted 
to a comprehension of the case as a whole ; let it be re- 
membered that each case demands special study and a plan 
of treatment adapted to its needs. The lesions themselves, 
as a rule, except in the case of local diseases, call for but 
secondary treatment; they are of little consequence when 
compared to the cause which is continually producing new 
lesions. When, however, as but too frequently occurs, no 
cause for the disease is to be detected, the lesions themselves 
should be vigorously attacked by every means at hand, with 
a view of removing them as soon as possible. In those in 



TREATMENT. 83 

stances in which the affection is known to be altogether local 
in its origin, nothing further than the treatment of the lesions 
themselves is called for. 

Method of Treatment. — For the relief of diseases of the 
skin, speaking in general terms, both constitutional and 
local remedies are demanded. They may be prescribed con- 
jointly or alone, according to the nature of the disorder. 
Experience proves conclusively that in many cases consti- 
tutional or internal treatment is by far the most effective, 
while in other instances local measures offer not only the 
best, but at times the only, means of relief; such being the 
case, I think, therefore, it is plain that neither method em- 
ployed to the exclusion of the other is capable of yielding 
the best results which it is possible to obtain. Where, how- 
ever, external means are sufficient to relieve the trouble both 
promptly and permanently, internal treatment is not only 
superfluous, but may even be productive of harm. 

Viewing the subject as a whole, I am strongly of the 
opinion that the most satisfactory results are to be obtained 
from the conjoint employment of both plans of treatment. 
The affections, and more particularly the individual cases in 
which either local or constitutional remedies are to be pre- 
scribed, can be determined only by taking into account both 
the nature and cause of the complaint under consideration. 

No positive rules can be given for the use of either one or 
the other class of remedies, for it will be found that the 
skin, when in a state of disorder, is a sensitive organ, sub- 
ject to no fixed laws of behavior. The remedy suitable for 
one stage is frequently not only powerless, but often abso- 
lutely injurious, in another stage of the same disease; this 
observation may be verified not infrequently in clinical ex- 
perience. 

CONSTITUTIONAL TREATMENT. 

Under this heading may be considered the following: 
Hygiene. — In this connection may be mentioned the bene- 
fits to be derived from attention to the ordinary rules of 
hygiene. In not a few disorders, especially those of a 
chronic nature, much is to be gained from regulated and 
judicious exercise, more particularly out-door exercise taken 



v [ TREATMENT. 

in sunshine. The advantages resulting from this adjuvant 
in therapeusis are most strikingly seen in cases in which 
there are marked elements of chlorosis present. 

The effect of change of climate upon certain serious dis- 

- 18 at times followed by the most salutary results. In 

certain rebellious cases of urticaria, psoriasis, furunculus, 

and eczema, the change may be followed by decided, and at 

times prompt, relief. 

Food.— Quite as important for the permanent relief of 
certain disorders as medicine itself, is the use of a well- 
regulated and suitable diet. The kind and quality of the 
food consumed are considerations of consequence in the 
treatment of a number of diseases. The diet should always 
be directed, and should consist of those articles which are 
suggested as being proper for the case under care. Bene- 
ficial results may also sometimes be obtained from a complete 
change of diet. 

Cod-liver Oil. — This remedy is an exceedingly valuable one. 
It is especially useful in all those cases in which the general 
health has become impaired through improper and insuffi- 
cient food, bad hygienic surroundings, and like causes. It 
is prescribed to greatest advantage in scrofuloderma, affec- 
tions of the sebaceous glands, lupus, and eczema. It may 
be administered to infants and children as well as to adults. 
The dose should always be liberal, varying from a teaspoon- 
ful to a half-ounce or more, according to the age of the 
patient and the tolerance of the stomach. 

Iron. — The preparations of iron occupy a conspicuous po- 
sition among the remedies used in the treatment of skin 
diseases. Their administration is indicated in a very large 
number of affections. They are given with particular benefit 
in diseases dependent upon chlorosis, and in exudative dis- 
eases accompanied by general impoverishment, as in certain 
forms of eczema, psoriasis, and the like. Many other dis- 
orders, too numerous to mention, may also be benefited by 
its judicious use. It may be prescribed in the form of the 
protocarbonate, citrate, pyrophosphate, or tincture of the 
chloride; the wine of iron may here be referred to as a very 
desirable preparation, suitable for many conditions, where a 



TKEATMENT. 85 

mild tonic is required; it constitutes an excellent vehicle for 
the administration of both arsenic and iodide of potassium. 

Quinine. — This may often be given with advantage where 
iron is indicated. It is found, however, to be of particular 
value in the neuroses, and in other diseases complicated by 
a well-defined nervous element. 

Arsenic. — As is well known, arsenic has long been held 
in high esteem as a remedy in cutaneous medicine. At the 
present day there exists a great diversity of opinion concern- 
ing its actual worth as a therapeutic agent against this class 
of diseases ; certain dermatologists claiming to derive marked 
good from its employment in quite a number of affections, 
while others of equal experience are inclined to place bat 
little reliance upon its curative powers. Without hesitation 
I would express myself of the opinion that it is a remedy of 
great value; that it is, in fact, the most valuable of all in- 
ternal remedies in the treatment of a number of skin dis- 
eases; but the cases in which it is prescribed must be selected 
if gratifying results are to be looked for. To say that arsenic 
is of use in "diseases of the skin," viewed collectively, is an 
assertion so vague and meaningless as to be of no practical 
value whatever. It is indeed a grand error to think that it 
may be prescribed in all cases. Not only is it necessary to 
specify the disease, but also the very stage of the affection, if 
we would employ it successfully. 

Arsenic exerts its influence chiefly upon the mucous layer 
of the epidermis. Hence it is found that diseases involving 
the more superficial parts of the skin are most benefited by 
its administration. It possesses little or no power over the 
affections which have their seat in the deeper structures; it 
has but slight effect upon deep infiltrations of the corium. 

Its action upon the skin is slow, weeks and months being 
requisite to produce the desired result; improvement once 
obtained, it is expedient to allow the patient to continue its 
use for some weeks after all symptoms of disease have dis- 
appeared. 

Arsenic should never be given in the acute, inflammatory 
stage of any disease of the skin ; it should never be pre- 
scribed when there is great heat, burning, intense itching, 



g(3 TREATMENT. 

or rapid cell change. It is not only of no good at this time, 
but is positively injurious, tending to augment the activity 
of the morbid process. It stimulates the rete into action, 
when rest is demanded. Its administration, then, in what- 
Boever disease, should be withheld until the acute symptoms 
have completely subsided. 

Arsenic is unquestionably of great value in psoriasis; but 
it is not of benefit in every case, nor should it be directed in 
all stages of this disease. Where the process is very active, 
and attended with intense hyperemia, it only increases the 
already inflammatory condition. The more active the cell 
proliferation, the less probability is there of its being bene- 
ticial. On the other hand, the more indolent and sluggish 
the process, the greater the chance for improvement. It may 
be stated, as a rule, that arsenic should always be withheld 
until the disease has fairly settled in its career. 

It is of decided service in certain varieties of eczema, es- 
pecially in the papular and squamous forms; also, I think, in 
those cases where the true primary lesions are but ill defined 
and where there is but slight infiltration of the skin. Certain 
persistent, localized papular and abortive vesicular eczemas, 
as frequently seen, for example, about the fingers, also often 
yield readily to it. Viewing, however, the subject of the 
value of arsenic in eczema in a broad light, I may state that 
its employment is not very satisfactory ; over the great mass 
of cases it possesses but little controlling power. 

Pemphigus is frequently materially influenced, and at times 
permanently relieved, by its judicious use; here, as in other 
conditions, the older the process the more likely are we to 
obtain favorable results. In the later stage of lichen planus 
it is prescribed with decided advantage. In certain forms of 
acne, especially in those cases where the lesions are numer- 
ous and of a fine papular character, its administration is 
frequently followed by good results. 

The preparations of arsenic which it is advisable to employ 
are arsenious acid, liquor arsenici chloridi, and liquor potassii 
arsenitis (Fowler's solution). The latter will be found the 
most desirable form for ordinary use. 

Arsenious acid is given in pill form, usually combined with 



TREATMENT. 87 

black pepper and powdered liquorice, constituting the com- 
pound known as the Asiatic pill, which maybe prescribed in 
varying strength, suitable to the case. The following is the 
formula somewhat modified: Arsenious acid, two grains; 
black pepper and liquorice powder, of each thirty-two grains, 
with a sufficient quantity of mucilage ; mix, and divide into 
thirty-two pills. S. — One to be taken three times a day, 
directly after meals. The strength of the pill may be altered 
to suit the case. 

The liquor potassii arsenitis is best given combined with a 
bitter tincture, or with the wine of iron. Prescribed in this 
way there is less likelihood of gastric and intestinal derange- 
ment. The mode of ordering the solution pure, and direct- 
ing so many drops to be taken at each dose, is, I thinly, objec- 
tionable for many reasons, to which it is unnecessary to refer. 
The average dose which will be found to be suitable to the 
majority of individuals is three minims. Four, five, and six 
minims, and even larger doses, will often be tolerated ; out 
of a number of patients, however, comparatively few will be 
able to take more than three or four minims for any length 
of time without derangement of the system. The solution 
of the chloride of arsenic is prescribed in about the same 
dose and for the same objects as Fowler's solution. At times 
large doses will be tolerated. Arsenic should always be given 
either with the food or directly afterwards. Its toxic effects 
should always be watched for and guarded against. 

Phosphorus. — The diseases in which this substance may be 
prescribed are those in which iron and arsenic would seem 
indicated. It is not well tolerated by the stomach, and it is 
partly on this account, probably, that the views of observers 
as to its efficacy are conflicting. It has been used with suc- 
cess in psoriasis. It is best administered in the form of a 
phosphorated oil, enclosed in capsules, the dose being about 
one-fiftieth of a grain of the phosphorus. 

Tar, Carbolic Acid. — Both of these substances are at times 
employed internally in psoriasis with good result. Tar should 
always be ordered in capsules. 

Mercury. — The preparations of this metal are rarely directed 
for disorders of the skin other than those of a syphilitic 



88 TREATMENT. 

nature. In this class of diseases, however, they are inval- 
uable. The corrosive chloride, protiodide, biniodide, and 
gray powder, are the forms in which it is commonly pre- 
scribed. The effect of the mercurials upon the system should 
always be noted with the greatest care, and in no case should 
they be pushed until ptyalism has been produced. Mercury 
is also combined very advantageously with iodide of potas- 
sium. Here may be mentioned Donovan's solution (liquor 
arsenici et hydrargyri iodidi), a remedy of some repute in 
the treatment of syphilitic manifestations. 

Iodide of Potassium. — This substance finds its chief use in 
scrofuloderma, lupus erythematosus, lupus vulgaris, and in 
the late syphilodermata. In the last named class of affec- 
tions it may be administered either alone or in combina- 
tion with mercury. It is prescribed in doses varying from 
five to twenty grains, largely diluted with water. 

Aperients. — This class of remedies is of great service in 
many of the inflammatory diseases. Saline laxatives, as the 
sulphate of magnesium, Rochelle salt, are especially to be 
recommended, and may be given with marked benefit in the 
early stages of the majority of the exudative diseases in 
which pyrexic symptoms are present. They should, how- 
ever, be used with discretion, and never to the extent of 
violent purgation. They are found to be most useful when 
prescribed with other substances, as, for example, iron, acids, 
and barks, in the form of a draught. 

Mineral Spring Waters. — These, especially those possessing 
cathartic and alterative properties, are at times taken with 
decided benefit. 

Diuretics. — Remedies exerting an eliminating influence 
upon the kidneys are administered with marked advantage 
in highly inflammatory diseases complicated with defective 
excretion, as, for example, in cases of eczema and psoria- 
sis. Saline, non-stimulating preparations are preferable, the 
citrate, acetate, and bicarbonate of potassium, in twenty or 
thirty grain closes, being those from which the most relief 
is usually to be derived. 

The alkalies are found to be of particular value in cases 
dependent upon or complicated with gout or rheumatism. 



TREATMENT. 89 

The condition of the urine should receive careful attention 
in all diseases of the skin, but especially in the acute exuda- 
tive disorders, where it is apt to be deranged. 

LOCAL TREATMENT. 

External remedies are used with the view either of tem- 
porarily relieving, or of curing the condition. They are 
very numerous, and include a great variety of substances, 
which are employed alone or in combination. They may 
be conveniently considered under the following heads. 

Baths. — Water, used for the purpose of cleansing the skin 
and removing from the surface effete matter, as scales and 
crusts, or in the form of baths, simple or medicated, is an 
essential therapeutic agent. Its employment should, how- 
ever, always be directed with judgment, inasmuch as in cer- 
tain morbid conditions it is liable to produce more mischief 
than good. Where plain water is required, care should be 
taken to procure soft or rain water. Many waters are hard 
and irritating to sensitive skins. 

The simple warm bath is especially serviceable in certain 
exudative diseases, as psoriasis, and in hypertrophies of the 
epidermis and corium, for example, ichthyosis. 

Medicated baths are prepared with various substances. 
Starch, bran, gelatine, and the like, are added to the plain 
bath for the purpose of obtaining a bland, unirritating water, 
which finds its chief use in highly inflammatory conditions. 

Alkaline baths, made with the carbonates of sodium and 
potassium, are of decided value in the neuroses and in para- 
sitic diseases; also in the desquamative stage of some of the 
exudative affections. Tar and sulphur, as well as other 
remedies, are also occasionally prescribed in the form of 
baths. Cold, douche, vapor, and hot-air baths are likewise 
often useful. 

The continuous bath, so constructed that a patient is 
enabled to remain continuously in the water for days and 
weeks at a time, is valuable in the treatment of extensive 
chronic inflammations, as psoriasis and pemphigus, and in 
burns. 

Soaps. — Two varieties of soap are made use of, the soda or 



90 TREATMENT. 

hard, and the potash or soft. Both are exceedingly important 
therapeutic agents, and are brought into frequent requisition 
for various purposes. Castile soap, the representative of the 
hard soaps finds its office mainly for cleansing the skin of 
extraneous matter, as dirt. It is a neutral soap, is quite 
bland in its effects, and may be advantageously employed 
in many diseases preparatory to the application of other 
remedies. 

Soft soap, termed also " sapo mollis" and " sapo viridis," 
is a soft, brownish or greenish soap, containing an excess, 
in varying amounts, of caustic potash. The fatty substance 
from which it is made may be either animal fat or vegetable 
oil ; it may further be either pure or impure in quality, 
points of difference in the manufacture which account for 
its variable characters as to consistence, color, odor, etc. 

Sapo viridis is an indispensable remedy in the hands of the 
dermatologist; it may be used alone, with water, with alcohol 
in the form of a tincture, or in combination with oils and 
other substances. It is an invaluable detersive agent, and 
is usually sufficiently strong to free the skin of scales, crusts, 
and other foreign matter. Its effect upon the skin is mildly 
caustic. When applied for any length of time, or repeatedly, 
its caustic property should be counteracted by the subsequent 
application of some oily or fatty material, to prevent rough- 
ness, chapping, and contraction of the epidermis. 

Medicated soaps, as, for example, those containing tar and 
sulphur, are at times serviceable in the milder forms of dis- 
ease; as a rule, however, better results are to be obtained 
from the same substances in other form. 

Poultices. — Preparations of this kind have but a limited use 
in dermatology. They are occasionally useful for removing 
large, adherent masses of crust, as in severe aud long-standing 
eczema of a part. They are also employed with great benefit 
to relieve pain and to hasten suppuration in furuncle, car- 
buncle, and like inflammations. They may be prepared with 
flaxseed meal, potato starch, or bread and milk, and should 
always be applied as hot as the part will bear, and should be 
repeatedly renewed. 

Dusting Powders.— These play quite an important part in 



TREATMENT. 91 

the management of certain of the hypenemic and inflam- 
matory disorders, as in erythema, intertrigo, and eczema. 
They are composed either of one or of several substances, 
mixed in varying proportions. "Wheat starch, corn starch, 
oxide of zinc, lycopodium, asbestos, French chalk, orris ro,ot, 
and arrow root, reduced to line, impalpable powders, are all 
used for this purpose. They should be prepared with care, 
and should be perfectly smooth and free of all grit. When 
applied, they serve to protect the surface from the influence 
of the air, from irritation and rubbing, and absorb exuded 
fluids. 

Lotions. — Lotions constitute a very desirable and cleanly 
means of applying a number of remedies. In many instances 
they are better adapted for the relief of disease than oint- 
ments ; this is particularly the case when the affection oc- 
cupies a large amount of surface, as in pruritus. They may 
very properly be divided into those which are soothing, 
stimulating, and astringent. 

Soothing lotions are usually aqueous. preparations contain- 
ing certain substances which allay nerve irritation and pro- 
duce ease; those in common use are black wash, lead water, 
glycerine and water in various proportions, weak solutions 
of carbolic acid, hydrocyanic acid, and the weaker alkalies. 
These find their use chiefly in the inflammatory affections, 
and most frequently in eczema. 

Stimulating lotions commonly contain alcohol, certain 
oils, aqua ammonias, cantharides, carbolic acid, corrosive 
sublimate, tar, alkalies, camphor, sulphur, etc.; often several 
of these substances are contained in the preparation. They 
prove of great value in affections of the scalp, where oils 
and ointments are contra-indicated on account of the hair. 
They are also of service in diseases of the glands, and in 
chronic inflammations, as in acne and eczema. 

Astringent lotions are made with alcohol, tannic acid, 
alum, iron, vinegar, and like substances; their principal 
employment is in hemorrhages, and in excessive sweating. 

Oils. — Xatural oils may be either bland or more or less 
stimulating. To the former class belong olive oil, oil of 
sweet almonds, linseed oil, castor oil, cod-liver oil, and petro- 



TREATMENT. 

lenm and its products vaseline and cosmoline. Here may 
also be mentioned glycerine, one of the most precious of 
external remedies. Bland oils are serviceable in softening 
scales and crusts, and for anointing the surface in a variety 
of conditions. They also enter largely into the composition 
of ointments and lotions. 

Examples of stimulating oils are found in the derivative 
oils from tar, as oil of cade, and oil of birch, and in oils 
derived from certain nuts, as the oil of cashew-nut, etc. 

Ointments. — Ointments constitute the usual and by far the 
most valuable means of applying remedies to the skin. They 
are made with various fats, commonly, however, with lard, 
and contain one or more substances upon which their chief 
virtue depends. Like the lotions and the oils, they may be 
divided into those which have a soothing effect, and those 
which stimulate. 

Sedative Ointments. — In this class may be placed simple 
ointments and cerates, glycerine ointments, ointment of 
cacao butter, cucumber ointment, diachylon and oxide of 
zinc ointments, and other preparations possessing similar 
properties. They are bland in their nature, and are em- 
ployed chiefly in highly inflammatory conditions, with the 
view of protecting the surface and of thus allaying irritation. 

Diachylon ointment, prepared either from diachylon plaster 
or from litharge, with olive oil, is an indispensable remedy 
in the treatment of a number of conditions. Oxide of zinc 
ointment is likewise an invaluable preparation, finding one 
of its principal uses in eczema. Both of these ointments are 
very frequently made to serve as vehicles for the application 
of other remedies. 

Stimulating Ointments. — These are the most efficacious of 
remedies. They are made with a great variety of substances, j 
which are employed either alone or in combination. Tar 
and its derivatives may first be mentioned; they are invalu- i 
able in eczema and psoriasis. Pix liquida, oil of cade, and 
oil of birch, are the products which are ordinarily employed. 
Carbolic acid occupies a position no less important than tar; 
in suitable strength it is the most valuable of antipruritic 
remedies. 



TREATMENT. 93 

The preparations of mercury, including the red oxide, 
nitrate, red iodide, mild chloride, corrosive chloride, ammo- 
niated mercury, and mercury itself, are all employed, and 
are very highly prized for their virtues in numerous and 
quite different diseases. Sulphur may also be referred to as 
one of the more important remedies of this class. Camphor 
and the subnitrate of bismuth, both mild stimulants to the 
skin, are occasionally used in the form of ointment with good 
result. 

Stimulating ointments are made in various strengths, from 
a few grains to several drachms of the active ingredient to 
the ounce of simple ointment, according to the nature of the 
case and the effect desired. 

Caustics. — Under this head may be classed those substances 
and preparations which are discutient in their effect, as well 
as those which are truly caustic. To the former belong 
iodine, sapo viridis, mercurials, acetic acid, cantharides, and 
the like. Among the stronger remedies, nitrate of silver 
occupies a conspicuous place; it is employed both in stick 
form and in solution. It is of service in those cases where 
a mild caustic or stimulating effect is desired, as in lupus, 
and in ulcers; also in various superficial formations. 

Caustic potash, either in stick form or in solution, is a very 
valuable, potent, and thoroughly efficient escharotic. It is a 
powerful remedy, exceedingly rapid in its destructive effects, 
and should always be used with caution. It is applied with 
good result in new growths and hypertrophies, such as epi- 
thelioma, lupus erythematosus, lupus vulgaris, and in other 
affections. It may be employed either in its pure state, or 
weakened by admixture with other substances, as lime, in 
the preparation known as potassa cum calce. The chloride of 
zinc is likewise a strong caustic, producing its effect slowly, 
but occasioning great pain both at the time of the application 
and for some time after the operation. It is of service in 
similar cases in which potash would be called for. Chromic 
acid is a mild caustic, useful in epithelial hypertrophies, as 
warts and like affections. Arsenic is chiefly employed with 
other substances in the form of ointments and powders; it 
is prescribed in certain cases of lupus, and as a stimulating 



04 TREATMENT. 

dressing in indolent ulcers. As a caustic it is slow but 
destructive in its action; it possesses the peculiarity of at- 
tacking diseased tissue in preference to healthy structures. 

Nitric acid and the acid nitrate of mercury are well adapted 
for the treatment of venereal productions, as chancres, warts, 
etc. They should he applied with care. Acetate of zinc, 
carbolic acid, corrosive chloride of mercury, and other sim- 
ilar agents, are occasionally used for purposes of superficial 
cauterization. 

Parasiticides. — These are remedies which act destructively 
niton both the vegetable and the animal parasites of the 
skin. 

Sulphur and its compounds, including sulphite of sodium, 
hyposulphite of sodium, and sulphuret of potassium, are de- 
serving of the first mention ; they are effectual in both groups 
of diseases. Sty rax and Peruvian balsam are especially 
valuable in destroying the itch mite ; while staphisagria, 
cocculus Indicus, white precipitate, mercurial ointment, cor- 
rosive sublimate, and petroleum are the best remedies against 
the pediculus. 

The vegetable parasites are acted upon by a number of 
articles, among which the mercurials, more particularly cor- 
rosive sublimate, the red and white precipitates, the yellow 
sulphate, and the red sulphuret, are to be considered as hold- 
ing a high position. 

Other remedies also serve the same end, as, for example, 
tar, creasote, carbolic acid, veratria, carbonate of potassium, 
borax, alcohol, iodine, cantharides, etc. 

Electricity. — This therapeutic agent may be applied with 
excellent result in certain affections, especially in those in 
which there is marked involvement of the nervous system, 
as in herpes zoster, and in the neuroses. The galvanic 
current— from five to fifteen cells, according to the suscepti- 
bility of the patient and the condition— is that from which 
the best effects are obtained; the faradic current is also 
serviceable. 

The application may be either central, through the system, 
or directly to the disease of the skin, by far the more useful 



TEEATMENT. 95 

method. Electrolyzation, or the decomposition of tissues by 
means of the galvanic current, is of value in the treatment 
of certain tumors, tubercles, connective-tissue growths, etc. 
It is accomplished by means of needles, in the place of ordi- 
nary electrodes, inserted into the tissues through which the 
current is discharged. 



PROGNOSIS. 

Concerning prognosis little is to be said in a general way. 
The question here is with individual cases of disease rather 
than with classes. 

Diseases of the skin are either acute or chronic ; some 
are invariably acute in their duration, as in the case of the 
herpes group; others are almost always chronic, as, for ex- 
ample, psoriasis. The vast majority of disorders, however, 
taking a general view of the whole field, incline to chronicity 
as regards duration ; many of them are exceedingly obsti- 
nate, lasting years; others, as those of a congenital nature, 
commonly continue throughout life. 

Anomalies of secretion are very often rebellious to treat- 
ment, as seen in seborrhcea and in hyperidrosis. 

The active hyperemias, as long as they remain such, are 
ephemeral derangements, and need occasion no anxiety. 
But it must be remembered that if the action of the cause 
is prolonged or carried beyond a certain point, the process 
becomes inflammatory, and the prognosis consequently more 
serious. 

Of exudative diseases as a class it is not possible to speak 
in general terms; for while some always terminate favorably 
and within a defiuite period, others may end very disastrously, 
as, for example, pemphigus; this latter result is, however, 
rare. A number of the inflammatory affections tend to be- 
come chronic, lasting not infrequently months or years; as 
instances, eczema, psoriasis, and non-parasitic sycosis may be 
cited. 

Hemorrhages are to be looked upon either in a favorable 
or in an unfavorable light, according to their severity and 
extent. 
96 






PROGNOSIS. 97 



Hypertrophies, as a rule, have a benign character ; they 
are slow in their course, and often continue a lifetime. Some 
of them are incurable. 

The same may be said of atrophies. 

Xeoplasmata or new growths are either benign or malig- 
nant. The prognosis with diseases of this class will depend 
altogether upon the nature of the case under consideration. 
Lupus, syphilis, leprosy, carcinoma, and sarcoma must all 
receive grave prognoses ; they are serious maladies, several 
of which frequently terminate fatally; on the other hand, 
certain affections of this class, as fibrous molluscum, give 
rise to no trouble beyond disfigurement. 

The neuroses are exceedingly variable in their duration ; 
at times they yield readily to treatment, in other cases they 
are most obstinate. They are always very distressing to the 
patient. 

The parasitic affections are all curable. 



CLASSIFICATION. 



The use of a classification in the consideration of diseases 
of the skin is to group together, for purposes of study and 
reference, affections which are similar in their intimate 
nature. Various ways of accomplishing the same object 
have been proposed. The method which appears to me to 
be the most practically useful, and at the same time capable 
of the most extended and scientific elaboration, is based upon 
anatomy and pathology. 

The arrangement which I present is that of Hebra, modi- 
fied. It rests entirely upon anatomical and pathological 
grounds, with the exception of the last class, which is etio- 
logical. In the great majority of instances the nature of the 
pathological process, together with the structure involved, 
serves as the basis for the grouping of the diseases. 



CLASS I. ANOMALI^E SECKETIOXIS— DISORDERS OF SECRE- 
TION. 



Seborrhcea. 

Comedo. 

Milium. 

Molluscum Sebaceum. 

Sebaceous Cyst. 



Sebaceous Glands. 



Hyperidrosis. 

Bromidrosis. 

Chromidrosis. 

Anidrosis. 

sudamixa. 



Sweat Glands. 









CLASSIFICATION. 



Erythema Simplex. 
Erythema Intertrigo 



CLASS II. HYPEREMIA— HYPEREMIAS. 

> Erythematous. 



99 



CLASS III. EXSUDATIONES— EXUDATIONS. 



Erythema Multiforme. 
Erythema Nodosum. 
Urticaria. 



Erythematous. 



Eczema. 



) Erythematous, Vesicular, Pustular, 
/ Papular, Squamous. 



Herpes Febrilis. 
Herpes Zoster. 
Herpes Iris. 
Miliaria. 



Vesicular. 



Pemphigus. 



Bullous. 



Lichen Planus. 

Prurigo. 

Lichen Scrofulosus. 



Papuh 



Acne. 

Acne Rosacea. 

Sycosis Non-Parasitica. 

Impetigo. 

Impetigo Contagiosa. 

Ecthyma. 



Pustular. 



Psoriasis. 
Pityriasis Rubra. 



\ Sqi 



furunculus. 

Anthrax. 



i Phlegmonous. 



Dermatitis. 



Erythematous, Vesicular, Bullous, 
etc. 



11)1) 



CLASSIFICATION. 



CLASS IV. HEMORRHAGIC— HEMORRHAGES. 
Purpura. } Corium, etc. 



CLASS V. HYPERTROPHIC— HYPERTROPHIES. 



Li:\ PIGO. 

Chloasma. 

N.KVI'S PlGMENTOSUS. 

Callositas. 

Clavus. 

oornu cutaneum. 

Verruca. 

i< hthyosis. 
Lichen Pilaris. 

Scleroderma. 
Sclerema Neonatorum. 
Elephantiasis Arabum. 
Dermatolysis. 



Pigment. 



Epidermis, Papilla?. 



J 



Corium. 



J 



Hypertrophy of the Hair. 
Hypertrophy of the Nail. 



} Hair. 
} Nail. 



CLASS VI. ATROPHIC— ATROPHIES. 



Albinism. 
Vitiligo. 

Canities. 

Atrophia Cutis. 

Stride et Macule Atrophica. 

morphgea. 

Senile Atrophy. 

Alopecia. 
Alopecia Areata. 
Atrophy of the Hair. 

Atrophy of the Nail. 



I- 



o:ment. 



Corium. 



Hair. 






} Nail. 






CLASSIFICATION 



101 



CLASS VII. NEOPLASMATA— NEW GROWTHS. 

[ Connective Tissue. 



Keloid. 

molluscum flbrosum. 

Xanthoma. 



Rhixoscleroma. 
Lupus Erythematosus. 
Lupus Vulgaris. 
Scrofuloderma. 
Elephantiasis Gr-ecorum. 
Syphiloderma. 
Carcinoma Cutis. 
Sarcoma Cutis. 



Cellular. 



N^vus Yasculosus. 
Telangiectasis. 



Bloodvessels. 



Lymphangioma Cutis. 
Lymphadenoma Cutis 

Neuroma Cutis. 



Lymphatics. 
} Nerves. 



CLASS VIII. NEUROSES— NEUROSES. 



Hyper jesthesia. 

Dermatalgia. 

Pruritus. 

Anaesthesia. 



Hyperesthesia. 
Anaesthesia. 



CLASS IX. PARASIT.E— PARASITES. 

Tinea Favosa. "} 

-, T. Circinata. I 
Tinea Tricophytina. I T. Tonsurans. L Vegetable. 

J T. Sycosis. 
Tinea Versicolor. 



J 



Scabies. 

Phtheiriasis Capitis. 
Phtheiriasis Corporis. 
Phtheiriasis Pubis. 



r Animal. 



PAET II. 
SPECIAL DISEASES. 



O L .a. s S I. 



ANOMALY SECRETIONIS— DISORDERS OF 
SECRETION. 

This class comprises an important group of diseases. It 
is composed of the various functional disorders of the seba- 
ceous and sweat glands. The aifections here considered are 
strictly those of abnormal secretion. Diseases of the glands 
accompanied by inflammation, as, for example, acne, find 
their place under the Exudations. 

SEBORRHEA. 

Syn. Pityriasis; Stearrhcea; Steatorrhea ; Fluxus Sebaceus ; Cutis Unc- 
tuosa; Acne Sebacea; Seborrhagia; Tinea Furfuracea ; Tinea Amiantacea ; 
Tinea Asbestina; Ichthyosis Sebacea; Dandruff; Dandriff; Germ., Schmeer- 
fluss; Gneis; Fr., Acne Sebacee. 

Seborrhea is a disease of the sebaceous glands, character- 
ized BY AN EXCESSIVE AND ABNORMAL SECRETION OF SEBACEOUS 
MATTER, FORMING UPON THE SKIN EITHER AN OILY COATING OR AN 
ACCUMULATION OF WHITISH OR YELLOWISH SCALES. 

Symptoms. — Seborrhea may appear upon any portion of the 
body, though, like the majority of cutaneous affections, it has 
favorite localities for its development. By far the most com- 
mon seat is the scalp ; next in frequency it occurs about the 
face. Upon the body it is seen most often about the back, 

102 



SEBORRHEA. 103 

between the scapulae, and upon the chest over the region of 
the sternum. It occurs at all periods of life, from birth to 
mature age. In newly born infants it constitutes the vernix 
caseosa or smegma, and may be present in a slight degree or 
as a thick coating involving the whole body, and is to be 
viewed as a physiological rather than a pathological process. 
It is apt to remain about the scalp in infants throughout the 
first few months of life, in the form of a compact, yellow, 
crust-like accumulation. The sebaceous glands by this time 
have begun to perform their function properly, and sebor- 
rhoea is not encountered again, as a rule, until puberty or 
adult age, when the glands are once more in danger of 
becoming deranged. 

The course of seborrhcea is variable. At times it is a 
very slight affection, disappearing either spontaneously or 
with simple treatment. In other instances it is severe, and 
continues for years, unless properly managed. The general 
condition of health influences its course in a very marked 
manner; as the tone of health improves, the glands tend 
to assume normal action. 

The state of the skin itself, beneath the scales, varies 
according x to the amount of disturbance as well as according 
to the character of the secretion. In the majority of instances 
the disease is in no way inflammatory, there being neither 
redness of the surface nor heat. In some cases, on the other 
hand, intense hyperaBmic signs are present, the skin being 
reddish in color, and the disease attended by burning and 
itching. These latter symptoms require further mention. 
The disease may or may not be accompanied by itching. It 
is frequently present, and at times is the source of distress 
to the patient. Often it is a prominent symptom, causing 
the individual to rub and scratch the skin. In the more 
hypersemic forms, as seen now and then about the cheeks, 
decided burning sensations are complained of. 

The general health of patients suffering from seborrhcea, 
especially in marked examples, is always below standard. 
They suffer from anaemic or chlorotic symptoms; pallor of 
the face, cold hands and feet, and other signs, to be spoken 
of in considering the subject of etiology, will usually be 



104 DISORDERS OF SECRETION. 

found. Seborrhcea is generally better in summer than in 
winter, and may even disappear in part or wholly during 
the hot weather. Until entirely relieved it is liable to 
relapse. 

There are two distinct varieties of seborrhcea, which are 
designated respectively seborrhcea oleosa and seborrhcea sicca, 
according to the character of the secretion poured forth. 

Inasmuch as the clinical appearances are quite different, I 
shall consider them separately. 

Seborrhcea Oleosa. — It appears in the form of an oily, 
greasy coating upon the skin, w T hich gives it both an unctu- 
ous look and feel. The secretion is decidedly oily in charac- 
ter, and may be in such quantity as to collect in drops upon 
the surface, when it will be seen to be a clear fluid, yellow- 
ish in color, and fatty in its composition. It shows itself 
upon both the hairy and the non-hairy portions of the body. 
Its most common seat is the region of the face, and more 
particularly the nose and forehead. Here it is generally 
observed as a greasy layer, containing more or less dust 
and fine particles of dirt derived from the air, looking as 
though the skin had been smeared with a dirty ointment. 
This product is given forth in varying quantities ; at times 
it is formed very slowly and occasions but trifling incon- 
venience to the patient, who manages to remove it by re- 
peated washings. In other cases, however, it is poured out 
in excess, and constitutes one of the most annoying of 
disorders. It is not often seen upon the hairy parts of the 
body. Upon the scalp it occurs more especially in those 
who are bald, giving the skin of the head the appearance as 
though it had just been oiled. Very marked examples of 
seborrhcea oleosa are not common. 

Seborrhcea Sicca. — This is the variety usually encoun- 
tered. It manifests itself upon both hairy and non-hairy 
regions. It consists in the formation of dry masses of scales, 
of a dirty white or yellowish color, which have a tendency 
to adhere to the skin. 

Seborrhcea must be considered first as it occurs upon the 
hairy parts, more particularly the scalp. 



SEBORRHEA. 105 

Seborrhcea Capitis, — This is not only the commonest local 
form of the disease, but also one of more than ordinary 
importance, on account of the disfiguring results which are 
apt to follow it. It is one of the most frequent sources of 
premature baldness. 

The affection is marked by the free formation of fine, 
whitish scales, which are ordinarily seen quite uniformly dis- 
tributed over the scalp. They may be either small, dry, and 
pulverulent, situated loosely upon the surface and detached 
from the hairs, or they may be in crust-like masses, ad- 
hering closely to the skin in the form of a coating. In these 
latter cases the hairs are, as it were, pasted down to the 
scalp. In either instance the scales fall off, and collect about 
the shoulders of the patient. If the scalp be not cleansed 
and the accumulations removed from time to time, large, 
thick masses or cakes are formed, which completely envelop 
the region, and prevent the hair from growing. The hair 
itself becomes affected; it is lustreless, dry, and apparently 
dead, and soon commences to fall out. This is but the 
beginning, the process eventually terminating in permanent 
and almost complete loss of hair. The follicles have been 
so long diseased by the morbid secretion of their glands that 
they have become structurally altered, and in many instances 
altogether obliterated. From these few remarks it will be 
noted that seborrhoea, although often an affection of appar- 
ently no great consequence, may, if permitted to run on, 
become quite serious in its character. 

If the scales be detached, the scalp is usually seen to be of 
a dull white or bluish-gray color, a peculiarly dead, anaamic 
hue, which is characteristic. This appearance is always 
present in sluggish cases, where the general health is ob- 
viously impaired. Seborrhoea may attack the whole of the 
scalp, uniformly, or only in places ; the former course is 
commonly observed. The crown of the head is its favorite 
locality; the sides are the next points of preference. 

Seborrhea Faciei. — Upon this region it is mostly ob- 
served in young people. It occurs about the forehead, on 
the cheeks, and over th-e nose, involving any one of these 
parts alone, or attacking all of them at the same time. It 



106 DISORDERS OF SECRETION. 

tends to assume the oily variety, although the dry form 
is also seen quite frequently. The skin may or may not 
be hypereemie. At times it is quite red, hot, and irritable, 
especially in the dry or squamous variety; in the oily form 
this is rarely observed. 

Seborrhoea oleosa may exist here in all degrees, from a 
very slight to a very marked disorder. It is seen as a 
shining, greasy film over the skin, generally showing itself 
about the cheeks and nose. The oily matter may be color- 
less, or it may be yellow or even of a darker tint. 

Seborrhoea sicca appears as a compact, thick, greasy secre- 
tion, often in the form of a mask to the part. It adheres 
firmly to the skin, and is bound down to it by the prolonga- 
tions of sebaceous matter which come directly from the 
follicles. These sebaceous crusts are seen about the cheeks, 
nose, and forehead, and are extremely disfiguring. In color 
they are usually bright yellow, but they may be grayish, 
greenish, or even blackish. Particles of extraneous matter 
at times collect upon the surface, and are even incorporated 
into the crust, giving it a still stranger appearance. The 
process is an active one, the crusts being readily replaced, 
in spite of frequent washings and other means employed 
for their removal. Itching and burning sensations often 
attend the disease in this locality, causing occasionally much 
distress; these symptoms, however, are not constant, but are 
subject to exacerbations, keeping pace with the activity of 
the process. In other cases, of a less hyperaemic type, no 
symptoms of this kind are experienced. 

Seborrhea Nasi. — This calls for special mention. The 
nose is ordinarily red, shining, and oily. The redness is 
usually marked, and is apt to give rise to more anxiety on 
the part of the patient than the secretion. The nose is not 
increased in size, nor is it swollen or hot, but, on the con- 
trary, is usually cold. The openings of the follicles are 
noted to be enlarged and patulous, a condition showing the 
absence of proper tone and vitality in the part. 

Seborrhoea of the face, and, in particular, of the nose, is 
one of the sequelae of variola, and often continues for a con- 
siderable time after the original disease. 



SEBORRHEA. 107 

Seborrhea Genitalium. — On account of the great num- 
ber and size of the glands about these regions, they are a fre- 
quent seat of seborrhoea. The condition is equally common 
in both sexes. In the male the glans penis and sulcus are 
the localities where it is ordinarily met with, forming a 
soft, whitish, cheesy mass, which collects about the parts. 
The same product is found in the female about the labia 
and clitoris. It may exist to a slight degree, scarcely con- 
stituting disease, or it may become copious and occasion 
inflammatory symptoms, which in the male, in cases of pro- 
longed prepuce, may result in balanitis. Decomposition 
of this sebaceous matter takes place very rapidly, and is 
greatly favored by moisture and heat. 

Seborrhcea Corporis. — It is very necessary to speak of 
the affection as it is encountered here, because it assumes 
features which are quite different from those which are seen 
elsewhere. The back, between the scapulae, and in front, 
the clavicular and sternal regions, are the two localities 
where, in the vast majority of cases, the disease appears. 
Both of these localities are very often attacked at the same 
time, but, owing to the difference in the anatomical structure 
of the skin, the lesions are somewhat unlike. 

Upon the back, patches are formed of varying size and 
shape; they may be the size of a finger-nail, or as large as 
the palm of the hand. They may exist separately, but they 
more often coalesce, forming one continuous patch. They 
are reddish in color, but, being partially covered with yel- 
lowish or grayish scales, often have a dirty look. The scales 
are rarely in any quantity; they are usually loose, and are in 
many cases altogether wanting, having been detached and 
rubbed away by the friction of the clothing. The mouths 
of the follicles are observed to be wide open, sluggishly 
discharging their secretion. 

These patches have no very defined outline ; they fre- 
quently involve the shoulders and upper part of the back as 
one large, imperfectly-developed patch. Acne papules and 
pustules are often seen here and there about these patches, 
establishing the anatomical seat of the disorder. The whole 
appearance at times resembles tinea versicolor of this region. 



piS DISORDERS OF SECRETION. 

Upon the chest the symptoms are somewhat different. 
Here the patches tend to assume a distinct circular shape; 
rings more or less complete occurring, which are made up 
of a reddish base, surmounted with pellicle-like scales. They 
are of a dirty white color, are greasy, have a withered, dry 
appearance, and are quite large in size. The patches have 
a well-defined outline; they may be either separate, as is 
usually the case, or they may have run together in the form 
of one large patch. There may be one, or two, or a dozen 
of them present. Seborrhcea of this region closely resem- 
bles tinea circinata. Both upon the back and chest it itches 
at times so much as to cause annoyance. It is very slow 
in its course, but subject to changes, being from time to 
time better and worse. It usually disappears during hot 
weather. 

Etiology. — The causes which give rise to seborrhcea are 
numerous, but depend for the most part upon an impair- 
ment of the general- health. Before referring to these, 
attention must be again directed to the fact that a certain 
amount of sebaceous matter upon the skin is normal, and 
highly conducive to the preservation of this membrane. In 
the newly-born infant, for example, the smegma serves a 
valuable physiological function. It is only when the secre- 
tion is produced in excessive quantity or in abnormal form, 
that the condition is to be regarded as disease. 

The causes giving rise to the two varieties of the affection 
are the same, peculiarities of the individual determining 
whether the process will take on the form oleosa or sicca. 
Persons with light hair and complexion are, I think, more 
prone to the dry variety, while those with dark hair and 
skins commonly exhibit the oily form. 

It was Hebra who first pointed out with clearness the fact 
that seborrhcea is in the majority of instances dependenl 
upon a chlorotic or anaemic state. This will in both sexes b( 
found to be the usual cause. Seborrheic patients are, as 
rule, thin and pale; have doughy complexions ; are poorb 
nourished; and are imperfectly developed throughout theii 
entire structure. The various functions of the body ar( 
apt to be deranged; especially is this the case in females. 



SEBORRHCEA. 109 

Hence it is that seborrhcea is so frequent at the period of 
puberty, when all the forces of the body are brought into 
action, and the functions common to adult life are regulating 
themselves. 

The disease occurs in both sexes, but is more often en- 
countered in females. It may show itself at any time of 
life, although it is ordinarily met with during early adult 
age. 

It may also exist upon persons who appear to be in other- 
wise excellent health, no appreciable cause for the disorder 
being recognizable. Such cases, however, are rarely obsti- 
nate, and generally give way to local treatment. 

As I have already pointed out, all those conditions char- 
acterized by general debility, faulty nutrition, and serious 
blood changes, may serve as causes of seborrhcea. The dis- 
order is observed to occur with or to follow the exanthemata, 
severe fevers, carcinoma, syphilis, tuberculosis, and allied 
diseases. 

Pathology. — Seborrhcea is a functional disorder of the seba- 
ceous glands, consisting in an increased and usually altered 
flow of the secretion. The sebum given out may be either 
oily or firm in its consistence, this difference giving rise to 
the several forms of the affection. In health it is known that 
the sebaceous glands discharge a variable amount of sebum 
in different localities; some parts of the skin, as the scalp, 
needing an abundant supply, other portions requiring but a 
small amount. 

Seborrhcea is most common where the glands are normally 
most active. It is altogether a functional derangement of 
the glands, no alteration taking place in their structure. At 
the same time, if the process be allowed to run on indefi- 
nitely, certain organic changes occur, as atrophy of the 
glands, follicles, and adjacent structures; this is frequently 
observed upon the scalp. 

The product of seborrhcea, examined with the microscope, 
is found to consist of an amorphous, fatty, slightly granular 
mass, together with numberless epithelial cells, coming from 
the lining walls of the glands and their ducts. The sebum 
and the scales vary as to proportion. The quality of the 



HO DISORDERS OF SECRETION. 

Becretion also varies, its nature depending to some extent 
upon peculiarities of constitution. 

Diagnosis. — Seborrhcea is a disease whose features vary 
greatly with the intensity of the process. It also presents 
very different appearances upon the various regions of the 
body. There are several affections which at times re- 
soluble it so closely as to make the diagnosis a matter of 
difficulty. 

Upon the scalp it may readily be mistaken for dry eczema. 
Seborrhcea, when present, usually occupies the greater por- 
tion of the scalp more or less uniformly; eczema is apt to 
be localized, appearing in distinct patches. The scales are 
abundant in seborrhcea; in eczema they are ordinarily 
scanty. The skin of a patch of seborrhcea is usually pale 
in color ; that of eczema is always reddish, and is more or 
less infiltrated and thickened. Seborrhcea is always a dry 
disease ; in eczema a history of moisture at some period in 
the course of the affection is very frequently obtainable. The 
itching of seborrhcea is never so intense as that of eczema. 
About the face it may also resemble eczema. The thick 
sebaceous crusts which occasionally occur upon the cheeks 
at times look not unlike those of eczema. 

Seborrhcea bears even a closer resemblance to psoriasis, 
whether occurring on the scalp or on the body. In sebor- 
rhcea the disease is usually uniformly diffused over the 
scalp ; in psoriasis the patches are, as a rule, irregularly dis- 
persed, with healthy skin between them; their outlines, 
moreover, are always sharply defined. In seborrhcea the 
scales are minute, yellowish in color, and have a greasy 
feel ; in psoriasis they are more abundant, much larger, 
thicker, and whiter. In seborrhcea the scalp is only ex- 
ceptionally hypersemic ; more frequently it is pale, anaemic, 
and leaden in color. In psoriasis the scalp beneath the 
scales is always reddish and inflamed. This latter point, 
it appears to me, is one of great value as an aid to diag- 
nosis. The histories, moreover, of the two diseases are very 
different. 

Seborrhcea of the scalp can scarcely be confounded with 
tinea tonsurans, but upon the chest it looks at times ex- 



SEBORRHEA. Ill 

tremely like tinea circinata. Its history, the slowness of its 
course, and the greasy appearance of the scales, together 
with their microscopic examination, will always serve to 
distinguish it from tinea circinata. 

The striking similarity between seborrhcea and lupus ery- 
thematosus renders the diagnosis now and then difficult. It 
must here be remembered that lupus erythematosus not in- 
frequently makes its first appearance as a seborrhoea. When 
fully developed, however, the distinctive features of lupus 
are sufficiently marked not to permit of error. Seborrhcea 
never possesses the sharp line of demarcation seen in lupus 
erythematosus; nor is it ever attended with such hyperamiic 
signs. Seborrhoea, moreover, is never accompanied by infil- 
tration and thickening, both constant symptoms of lupus. 
The patches of seborrhcea are either pale or reddish ; in 
lupus they are apt to be dark red, at times the color of raw 
beef, and are covered with flat, tenacious scales. Patho- 
logically, seborrhcea is a functional disorder; lupus is a new 
growth, composed of cells. Seborrhcea, finally, differs from 
lupus in that it is not followed by cicatricial tissue. 

Treatment. — Local and constitutional treatment are both 
to be considered. They may be employed separately or to- 
gether. Internal remedies are to be directed in those cases 
where there is obvious functional disturbance of some of 
the organs of the body, or where there is need for general 
constitutional treatment. The indications will be those symp- 
toms already referred to in speaking of the etiology of the 
disease. 

It is of importance that the patient be surrounded by 
proper hygienic influences. Abundance of fresh air and 
exercise are two valuable aids in the treatment of a certain 
class of seborrheas. Young girls, especially, should be 
made to take suitable daily exercise. The food should be 
of the best quality, and as nourishing as possible. Cod- 
liver oil, in full doses, should be prescribed, and taken for 
a considerable time; it will be found of great service in the 
majority of cases. The preparations of iron are, I consider, 
exceedingly valuable, and should be given in appropriate 
quantity, suitable to the case, for a period of some months. 



] 1 2 DISORDERS OF SECRETION. 

The tincture of the chloride of iron is the most efficacious 
form ; it should be directed three times a day, in ten minim 
doses, well diluted with water. The following formula will 
be found serviceable : 

R Tinct. Ferri Chloridi, fgi; 
Acidi Phosphorici dil., f f ^i; 
Syrupi Limonis, f^ii. 
M.— Sig. Half a teaspoonful three times daily with a wine- 
glassful of water. To be taken through a glass 
tube. 

Other ferruginous preparations, such as the carbonate of 
iron and the w T ine of iron, may be ordered as age and other 
conditions may require. In some cases arsenic in small 
doses acts beneficially, especially after a course of iron has 
been taken. It may be advantageously prescribed with wine 
of iron : 

R Liq. Potassii Arsenitis, f t ^i ; 

Yini Ferri, q. s. ad f^iv. 
M. — Sig. One teaspoonful three times daily directly after 
meals. 

In addition to the means indicated, all measures calculated 
to improve the health should be instituted, for in many cases 
it is only by attention to the general condition of the patient 
that permanent relief is to be secured. 

The local treatment is also of vast importance. It must 
vary somewhat as one region or another is the seat of 
disease. 

Seborrhcea capitis calls for special directions. If there be 
an accumulation of sebum and scales upon the scalp, they 
should be removed at once and the surface thoroughly 
cleansed, that a view of the skin itself may be obtained. 
This is very necessary in order that the state of the tissues, 
follicles, glands, and hairs may be noted. At times the 
mass of sebaceous material is so thick and inspissated that 
ordinary washing with soap and water is not sufficient to 
cleanse the head. When this is the case, one of the bland 
oils should be first rubbed in and allowed to remain for a 
while, which proceeding will soften and break up the crust. 






SEBORRHEA. 113 

Either olive oil or almond oil is to be preferred for this 
purpose. The patient is directed to pour a quantity of the 
oil upon the head, and to have it well rubbed in and the 
scales saturated with it. The quantity to be used will vary 
from one to several ounces, the amount necessary depend- 
ing upon the thickness of the hair, the number of scales, 
and the dryness of the scalp. Enough must be applied to 
soften and loosen the mass. The operation should be per- 
formed at night-time, just before the patient retires. A 
close-fitting cap, made of flannel, should be put over the 
head, and a bandage worn, in order to keep the oil from 
soaking through. In the morning the cap is to be removed 
and the scalp thoroughly washed with warm water and 
soap. Ordinary hard soap is usually not strong enough to 
free the head of oil and sebaceous matter; for this purpose 
the following formula will be found exceedingly valuable:* 

R Saponis Yiridis, ^viii ; 

Alcoholis, f^iv. 
Solve et filtra. 
Sig. To be used as -a soap-wash or shampoo. 

A tablespoon ml may be poured upon the head, together 
with a small quantity of water, which will at once produce 
a copious lather. This is to be rubbed into the scalp vigor- 
ously, and afterwards washed out with abundance of warm 
water. Sapo viridis may also be used alone with like result, 
but the alcohol acts serviceably upon the oils. The hair 
should now be carefully dried by means of soft towels; if 
very long and thick, it may be dried with the heat of a fire. 
Concerniuo; the cutting of the hair to facilitate the treat- 
ment, I would remark that this process is never necessary. 
The applications may be made with as much hope of success 
when the hair is long as when it has been cut. 

The washing and drying operation performed, it is now 
necessary to apply some oily or fatty substance. If this be 



* This preparation, and the mode of its employment, were introduced to the 
profession by Hebra. It may be made in various proportions, and perfumed 
to please the individual. Cologne water may be used in the place of alcohol. 

8 



114 DISORDEBS OF SECRETION. 

not done, both the hair and the scalp will become very dry 
and harsh. The application of some oil or other is, indeed, 
a part of this mode of treatment. The kind of oil or po- 
made to be used will depend in a great measure upon the 
condition of the scalp. If considerably irritated and exposed, 
one of the simple oils, as almond oil, or vaseline, should be 
applied. Equal parts of glycerine and water also constitute 
an excellent mild oily preparation, which may frequently be 
used with advantage. In the majority of instances, however, 
stimulating preparations will be found of greatest benefit. 
Carbolic acid acts very favorably in combination with an oil 
and alcohol: 

R 01. Eicini, f giv ; 

Acidi Carbolici, TT[xx ; 

Alcoholis, f.^iss; 

01. Amygdal. Amar., Vf[}^- 
M. — Sig. To be applied after washing. 

This is a useful formula, and may be ordered in a large 
number of cases. 

Tincture of cantharides, corrosive chloride of mercury, 
and other similar substances, may in like manner be em- 
ployed where direct stimulation is indicated. 

Ointments are also used with good effect, but their con- 
sistence renders their application unpleasant on account of 
the hair, which is apt to become matted and unmanageable. 
The red oxide of mercury and ammoniated mercury are in 
these cases especially useful, prepared in the strength of 
from five to ten grains to the ounce. I have of late pre- 
scribed the following with good result : 

R Hydrargyri Oxidi Kubri, gr. v ; 

Vaselin. ^i. 
M. Ft. ungt. 
Sig. A small quantity to be applied once a day. 

Having enumerated some of the preparations to be em- 
ployed after washing the scalp, further directions as to the 
frequency of these applications remain to be given. Ac- 
cording to the activity of the process, the quantity of the 






SEBORRHCEA. 115 

scales, itching, and the general condition of the head, the 
cleansing is to be repeated every day, every other day, or 
as occasion may seem to require. The oil or ointment is 
always to be used after each washing. At times, where the 
scales are not plentiful, it is expedient to apply the oil or 
ointment occasionally without previous cleansing. The treat- 
ment should be persisted in for weeks or months, until, in 
fact, improvement takes place. 

The local treatment of the face, body, and non-hairy 
regions is somewhat similar to that just described for the 
scalp. The masses of scales or of sebaceous crust are to 
be removed by frequent washings or warm baths, together 
with soaps of suitable alkalinity. After being well cleansed, 
sulphur ointments and lotions, alcoholic lotions, glycerine 
preparations, bland oils, or ointments are to be used as may 
appear indicated. The kind of application to be preferred 
must depend upon the condition of the part, upon the variety 
of the disease, upon the hyperemia present, and finally, after 
trial, upon those remedies which appear to act most bene- 
ficially. Sulphur, I think, stands forth as the most valuable 
remedy. 

Prognosis. — This must be materially influenced by the gen- 
eral condition of the patient and the likelihood of our being 
able or not to remove the cause. The variety of the sebor- 
rhea, as well as the region affected, is also to be consid- 
ered. As a rule, the affection is obstinate, yielding only 
after treatment has been vigorously continued for some 
time; months are frequently found to be necessary to alter 
the abnormal secretion. The most serious form is usually 
observed on the scalp, where, perhaps, it has lasted for some 
time and the hair has already begun to fall out; in these 
cases the prognosis is not favorable for a speedy termina- 
tion, nor for the restoration of the hair. When baldness 
has already occurred, a future growth of hair is not to be 
looked for, although much may be accomplished towards 
restoring to a state of health those follicles which have not 
been seriously involved. 

In infants the affection gives rise to no trouble, and is 
usually amenable to simple remedies. 



11 1 ; DISORDERS OF SECRETION. 



COMEDO. 

Comedo is a disorder of the sebaceous glands characterized 
by fellowish ('it whitish pin-point and pin-head sized solid 

ELEVATIONS, CONTAINING IN THEIR CENTRE AN EXPOSED BLACKISH 
POINT. 

Symptoms. — It is observed for the most part about the 
face, neck, chest, and back. Each single elevation or papule 
is designated a comedo, and they are spoken of in the plural 
as comedones or comedos. They may be very numerous or 
few; usually, where there is a tendency to their formation, 
they exist in numbers, giving a blackish, speckled or punc- 
tate appearance to the part. Their common situation is 
about the forehead, cheeks, and chin ; they are also seen on 
the back. In size they are small, varying from a pin-point 
to a pin-head. At times they form in great numbers upon 
every part of the face, and are then exceedingly disfiguring. 
In these cases they are apt to be quite black, and give the 
individual the appearance of having had minute grains of 
powder implanted in the skin. The skin has, moreover, a 
dirty, greasy, unwashed look. The condition is not attended 
with any sigu of inflammation, and gives rise to no subject- 
ive symptoms. The disfigurement ordinarily occasions the 
patient much mortification. Comedo occurs principally in 
young people, but is also seen in older persons, especially in 
men who are negligent of their person. The affection is 
very frequently associated with acne, to which disease it is, 
of course, intimately allied. Comedones come and go from 
time to time, although their course is naturally very sluggish 
and chronic. Their continuance, however, depends upon the 
nature of the cause and other circumstances. Without inter- 
ference they may last for years. Occasionally, notwithstand- 
ing the most energetic treatment, they prove exceedingly 
rebellious. 

Etiology. — The derangement is at times observed to occur 
in those whose skins are improperly cared for. Dust, fine 
particles of various substances, etc., which are continually 
floating in the air, all go to make up the comedo point. 



COMEDO. 117 

The true cause of the comedo is, I think, to be found, in 
the majority of instances, in disorders of the important func- 
tions of the body, as we so often observe in the case of acne. 
Those persons subject to or suffering from comedones are 
generally noticed to have a thick, muddy-looking skin, 
plainly showing a want of activity not only in the gland- 
ular structures but also throughout the whole integument. 
More or less constipation or irregularity of the bowels is 
almost invariably present in these cases; dyspepsia, with 
one or more of its numerous symptoms, is also apt to be at 
hand ; while patients will frequently be observed to exhibit a 
state of hebetude, denoting a general condition of sluggish- 
ness with reference to the various functions of the body. In 
young women chlorosis and menstrual difficulties should be 
inquired after; they are likely to be present. 

Pathology. — The affection has its seat in the sebaceous 
glands and ducts. It consists of an accumulation of sebum 
and epithelial cells in the glands and follicles, dilating the 
glands to such an extent as to produce the elevation upon 
the surface. The process is an inactive one ; is unattended 
by signs of irritation, and occasions no disturbance in the 
surrounding tissues. The obstruction may relieve itself or it 
may continue, distending the gland until a papule is formed. 
The comedo is readily removed by pressure exerted upon 
its walls. The mass is seen to consist of sebaceous matter 
with epithelial cells, dirt, and other foreign particles. The 
cells are filled with oil globules, and exhibit signs of fatty 
degeneration. 

Small hairs are frequently found in these masses, and also 
at times the microscopic acarus folliculorum. This little 
mite, however, is not to be viewed as in any way the cause 
of the disorder. It is altogether inoffensive in character, 
and is found to exist in healthy follicles quite as often as in 
comedones. 

Diagnosis. — Xo difficulty can arise upon this point. The 
affection is so commonly observed upon the face, that its 
features are well known to all. As stated, it is frequently 
encountered in connection with acne; the two processes, 
however, are distinguished by the absence of all inflamma- 



1 1 X DISORDERS OF SECRETION. 

torv symptoms in comedo. Milium is a disorder closely 
allied, both in its nature and in its appearance, to comedo. 
They differ in that milium contains no open duct, and is con- 
sequently without the characteristic black point of comedo. 
Milium is seated just beneath the epidermis, as a whitish 
little body, and cannot be forced out of the skin without 
rupturing or first incising its covering or roof. 

Treatment. — Local treatment suffices in many cases to 
relieve the condition. Frequent hot baths, with soft soap, 
followed by friction, often serve to stimulate the glands to 
normal activity. In addition to this, each comedo is to be 
treated separately, by expressing the contents of the follicle, 
which may be accomplished by means of a watch-key of suit- 
able bore, placed directly over the black point and pressed 
upon, when the contents will be forced out. The same result 
may be obtained, though less successfully, by squeezing the 
comedo between the thumb nails. A certain number of the 
lesions should be treated in this manner each day; until all 
the follicles have been emptied ; when they again become 
plugged, as often as this may happen, the same process is to 
be repeated until healthy action is assumed. Stimulating 
lotions and ointments are of service, and should be applied 
and allowed to remain on through the night. The following 
I have used with good result: 

R Sulphuris Sublimati, £ii j 

G-lycerinae, f^i ; 

Ungt. Adipis, q. s. ad %i. 
M. Ft. ungt. 
Sig. To be well rubbed in at nigbt. 

Alcoholic lotions, with or without sulphur, may also be 
employed with benefit. Together with the local measures, 
treatment for the improvement of the general health should 
at the same time be instituted, as the case may demand. 
Derangement of any of the functions of thfe body should 
always be corrected; proper diet and hygiene should be 
directed, and strict attention given to the ordinary rules for 
promoting health. The preparations of iron are of decided 
benefit in many cases, especially in chlorotic young women. 



MILIUM. 119 

Cod-liver oil I have also found to be of great service in 
many instances. 

Prognosis. — As a rule, no difficulty whatever is encountered 
in the removal of comedones, a few months, or less time, 
usually sufficing for their complete disappearance. Xow 
and then, however, they are remarkably obstinate, new 
ones returning from time to time in the same glands. The 
patient should in these cases always be encouraged, for, with 
a well-directed treatment, a favorable result must sooner 
or later occur. 

MILITJM. 

Syn. Grutum ; Tubercula Miliaria : Follicular Elevations : Tubercula 
Sebacea ; Acne Albida ; Pearly Tubercles ; Strophulus Albidus. 

Milium consists in the formation of small, roundish, 
whitish. sebaceous, non-inflammatory elevations, situated 
in the 6kin just beneath the epidermis. 

Symptoms. — Milia have their seat for the most part upon 
the face, especially on the forehead and about the eyelids; 
they may, however, occur on other parts of the body. They 
vary as to size from a pin-point to a small pea; their ordi- 
nary size is that of a millet seed, — hence the name. They 
may occur singly or in great numbers. In color they are 
white, pearl-colored or yellowish, and often have a translu- 
cent look, as though they might contain fluid. In form they 
are rounded or acuminated, and may be felt as more or less 
hard bodies imbedded superficially in the skin. They form 
very gradually and slowly, and when fully developed are not 
apt to undergo any change, but may remain in the same state 
for years. No mconvenience, beyond disfigurement, is occa- 
sioned by their presence. As a rule, they occur independent 
of the other disorders — as acne — of the glands. They are 
met with more commonly upon women than upon men, and 
usually first show themselves at middle age. 

In connection with milium, the so-called stones of the skin, 
or cutaneous calculi, may be referred to. They are usually 
milia, or sebaceous concretions, which have undergone meta- 
morphosis into hard, calcareous, or stone-like masses; they 
are met with only rarely. 



120 DISORDERS OF SECRETION. 

Etiology.— The causes of milium must be viewed as being 
similar to those which give rise to comedones and cysts of 
the sebaceous glands. In some cases, however, no cause can 
be assigned for its appearance. 

Pathology. — The affection has its seat in the sebaceous 
glands. It consists in an accumulation of sebum within 
the gland, which, owing to obliteration of. the duct, from 
some cause or other, is unable to escape. No sign of 
aperture is to be found; the contents cannot be squeezed 
out. Milia are completely enclosed. If carefully examined, 
it will be seen that they are located just beneath the epi- 
dermis, which constitutes their external covering. Neumann 
and others have found upon section that the covering proper 
is either the wall of the hair follicle or that of the gland 
itself, and that the larger milia contain connective-tissue 
septa running through them. The mass is made up of 
sebaceous matter, closely packed together and tending to 
become inspissated. 

Diagnosis. — Although milium and comedo are similar in 
appearance, they differ in one important anatomical par- 
ticular. In milium there exists a distended but enclosed or 
encysted gland, without opening; in comedo the duct of the 
gland is always patulous upon the surface. Milium usually 
exists alone, the rest of the skin being in good order ; co- 
medo is commonly associated with general derangement of 
the skin. The black point of comedo is another conspicuous 
distinguishing feature. 

Milium may, at times, bear some resemblance to sudamina, 
especially about the face. Incision, however, will disclose 
sebaceous matter in the one and sweat in the other. The 
affection is not to be confounded with xanthoma, a disease 
which usually has its seat about the eyelids, but is of a very 
different nature. 

Treatment. — The treatment consists in opening the little 
tumors by means of a knife and removing the contents. 
Each individual milium must be handled separately. The 
skin should be washed daily with hot water and soap, and 
stimulated with friction; it must be aroused to healthy 
activity and the glands induced to discharge their contents 



MOLLUSCUM SEBACEUM. 121 

normally. If they tend to return after removal, the same plan 
must be again employed and persevered in. 

MOLLUSCUM SEBACEUM. 

Syn. Molluscum Contagiosum ; Tumores Sebipari ; Molluscuni Sessile ; 
Condyloma Subcutaneuui ; Fr. Acne Varioliformis ; Tumeurs Folliculeuses. 

Molluscum sebaceum is a disease op the sebaceous glands 
characterized by rounded, semiglobular or wart-like tumors, 
of a whitish or pinkish waxy color, varying in size from a 
pin-head to a cherry. 

Symptoms. — Usually they are observed of the size and 
shape of a small split pea. They occur singly or in num- 
bers, and may ordinarily be seen in various stages of devel- 
opment upon the same patient. Their color is that of normal 
skin or pinkish ; they have a decided waxy look. At times 
they resemble a drop of white wax upon the skin. Upon 
their summit they are often flattened ; at times there exists 
a depression. In the centre a dark point, representing the 
aperture of the follicle, is commonly present; in other cases 
it is absent. They frequently have a glistening look, due to 
the skin over them being in a stretched condition. To the 
touch they are quite firm, their consistence depending, how- 
ever, upon the condition of the contents, which is liable to 
alteration. Their common seat is upon the face, neck, 
breast, and genitalia. They may also occur upon the head, 
and upon the extremities. They have a broad base, and are 
seated close to the surface. They increase in size with vari- 
able rapidity, sometimes rapidly, at other times slowly; are 
unaccompanied by inflammatory signs, and eventually ter- 
minate by disintegration and sloughing of the mass. The 
affection is attended at times by slight itching; in other 
cases it gives rise to but little iuconvenience. 

Etiology. — The disease is not common. It is observed to 
occur chiefly in children, and for the most part among those 
of the poorer class, who are neglected and ill fed. It may 
also occur in adults. Its cause is as yet unsatisfactorily ex- 
plained. In regard to its supposed contagious nature, the 
opinions of careful observers differ to such an extent that 
no definite conclusion can be reached. Inoculation with 



122 DISORDERS OF SECRETION. 

the matter, taken directly from the tumor, as performed by 
Eebra and others, failed to develop the affection. It should 
be stated, however, that it is not infrequently noted to attack 
.several members of a family, from which occurrence it is 
supposed by some to possess contagious properties. On the 
other hand, its presence limited to single cases in over- 
crowded children's asylums, is of equal weight against it3 
contagious character. 

The ground for the proof of its contagiousness is there- 
fore, I think, at present insufficient. I cannot recall a case 
in which the evidence of its contagious nature appeared to 
me to be conclusive. 

Pathology. — The disease has its seat about the sebaceous 
glands or hair follicles. If one of the tumors be incised 
with a knife, the contents may be expressed in the form 
either of a consistent, rounded body, yellowish in color, or 
of a milky, cheesy fluid. Microscopically, it is seen to con- 
sist of a mass, containing fat and large epithelial cells, with 
nuclei in abundance, and peculiar bodies, round or oval in 
shape, sharply defined, and fatty in appearance. If a section 
be made, hypertrophied connective-tissue septa may be ob- 
served, dividing the structure into lobules. Virchow does 
not believe that the affection is due to disease of the seba- 
ceous glands. He regards the process as a simple hyper- 
plastic formation of the cells of the lining wall of the hair 
follicle. Boeck considers the affection to be one of the 
rete mucosum.* 

Diagnosis. — Molluscum sebaceum should not be confounded 
with molluscum fibrosum, a very different disease, for which, 
however, it is at times mistaken. These two kinds of tumor 
may be readily distinguished by their anatomical characters. 
In molluscum sebaceum the disease is glandular in nature, 
consisting of an enormously distended sac, filled with seba- 



* For further information, consult 

Virchow, Archiv fur Path. Anat. und Phys., Bd. xxxiii. p. 144, 1865. 
Hilton Fagge, Guy's Hospital Reports, 1870. 
Dyce Duckworth, St. Bartholomew's Hospital Reports, vol. viii. 
Casar Boeck, Yierteljahresschrift fur Dermatologie und Syphilis, II. Jahr- 
gang, 1875, erstes Heft. 



MOLLUSCUM SEBACEUM. 123 

ceous matter and cells, which, as a rule, may be squeezed out 
of the duct. The opening of the duct is usually to be seen 
as a darkish point in the centre of a slight depression on the 
apex of the tumor. The growths of molluscum fibrosum are 
made up of a connective-tissue new formation, firmly seated 
in and beneath the skin, and possess a solid, fibrous feel. 
The little tumors of molluscum sebaceum usually occur 
about the face, and in limited numbers; those of molluscum 
fibrosum commonly appear about the body, and often in 
great numbers. The tumors of molluscum sebaceum are 
prominently raised from the skin, and are superficial in their 
seat; those of molluscum fibrosum are located in the skin 
itself, and even in the subcutaneous tissues. 

The tumors of molluscum sebaceum are small, and have a 
glistening, translucent, waxy appearance; those of mollus- 
cum fibrosum are much larger, and have a thick, solid, 
nodular, subcutaneous look. Molluscum sebaceum is, as a 
rule, a disease of infancy and childhood ; molluscum fibro- 
sum is an affection of adult life. 

The disease is also to be distinguished from papillary 
warts. The resemblance between these two affections is 
often very marked, particularly in those cases of molluscum 
which are imperfectly developed, the growth assuming more 
of an acuminated than of a rounded form. With attention 
to the characteristic anatomical lesions referred to, error can 
scarcely occur. 

Treatment. — Local remedies alone are required to relieve 
the disorder. The tumors are to be treated separately, and 
may be removed by the knife ; they may also be destroyed 
by means of caustic applications. When the opening of the 
follicle is widely distended, the contents may sometimes be 
squeezed out by firm pressure with the fingers against the 
sides of the tumor. Free but careful incision upon the top 
of the tumor is the best treatment, after which, in the ma- 
jority of cases, the mass may be easily forced out of its seat. 
If adherent, it should be extracted, together with its sac, by 
means of forceps. Nitrate of silver in stick form should be 
applied to the cavity and base after enucleation, in order to 
insure against return. 



1^4 DISORDERS OF SECRETION. 

They may also be treated with a ligature, when their bases 
are, in like manner, to be touched with the stick of nitrate 
of silver. Whatever the method of treatment adopted, it 
should never be heroic, for it must not be forgotten that the 
affection tends to spontaneous recovery. 

Prognosis. — The disease is very amenable to treatment, 
which, if properly carried out, is rarely followed by a return 
of the affection. If, on the other hand, the tumors are only 
partially destroyed or removed, the growth is apt to form 
again. 

SEBACEOUS CYST. 

S>/n. Encysted Tumor; Follicular Tumor; Sebaceous Tumor; Atheroma; 
Steatoma ; Wen. 

Sebaceous cyst appears as a variously-sized, roundish, more 
or less prominent tumor having its seat in the skin. 

Symptoms. — The skin covering sebaceous cysts is normal in 
color, or whitish, owing to extreme distention. The tumors 
may occur singly or in great numbers. In size they vary 
from a pea to a walnut and larger ; in shape they are rounded, 
and either flattened or semisdobular. In consistence thev 

O xl 

are either hard, or, as is more commonly the case, soft and 
doughy. They are freely movable, and are unattended by 
pain. 

The scalp, face, back, and scrotum are the favorite localities 
for the development of these formations. Their course is 
slow; not infrequently they exist for years without giving 
rise to inconvenience. At times, when excessively distended, 
they break down and ulcerate. 

Two kinds of tumors may be distinguished: one in which 
the duct is open, the other in which it is closed. Where the 
duct remains open, the tumor is usually flat in form, tending 
to extend itself laterally rather than above the level of the 
skin ; this variety is most frequently encountered on the neck 
and back. Where, on the other hand, the duct has become 
obliterated, constituting the true encysted tumor, the forma- 
tion assumes a semiglobular or even a globular form, pro- 
jecting itself prominently beyond the level of the skin ; it is 
common upon the scalp, and occurring here is usually devoid 
of hair. 



HYPERIDROSIS. 125 

Pathology. — The contents of sebaceous tumors are found to 
vary. The mass is ordinarily firmly encysted, and may be 
either soft and cheesy or hard and friable in consistence. It 
ma}* be yellowish or whitish in color; often it is very fetid. 
Occasionally the contents are fluid in character. The mass 
is composed of sebum, epidermic cells, crystals of choles- 
terine, and at times hairs. In structure these tumors are to 
be regarded as enormously distended sebaceous glands and 
ducts, whose walls have become so greatly thickened and 
hypertrophied by the continual pressure exerted upon them, 
as to form a thick, tough sac or cyst. 

Diagnosis. — Xo difficulty exists in the diagnosis; they may, 
however, be confounded with fatty tumors, and with the 
tumors of sebaceous molluscum. 

Treatment. — The treatment is excision. The cyst should 
always be carefully and thoroughly dissected out, without 
which precaution the disease is likely to be reproduced. 

HYPERIDROSIS. 
Sy?i. Idrosis; Sudatoria: Ephidrosis : Excessive Sweating. 

Hyperidrosis is a functional disorder of the sweat glands 
consisting in an increased flow of sweat. 

Symptoms. — It may vary greatly as to quantity; from 
slightly in excess of health to the pouring forth of very large 
amounts. The condition may exist as an acute or a chronic 
one. It may be either universal, involving the whole body, 
or local, attacking certain regions, as, for example, the palms 
and soles. 

Universal or general sweating is observed in the course of 
a number of diseases, as, for instance, in pneumonia, tuber- 
culosis, rheumatism, and various febrile maladies. It also 
occurs in those who are otherwise in perfect health, especially 
when exposed to the influence of a high temperature. In the 
majority of these cases it is scarcely to be considered in the 
light of a disease, although at times it may be so excessive 
as to call for treatment. 

Local hyperidrosis is always a disagreeable and trouble- 
some disorder. It may occur upon any portion of the body, 



126 DISORDERS OF SECRETION. 

but is more commonly encountered about the palms, soles, 
axillae, and genitalia. It may or may not be symmetrical. 
Numerous cases are recorded of its occupying only one side 
of the body, the forehead, cheek, arm, leg, and other single 
regions. 

The palms, soles, and genitalia are the parts usually at- 
tacked, and require special remark. These cases are of quite 
frequent occurrence. The sweat may be moderately copious 
or very excessive ; at times the quantity poured out is so 
great as to keep the parts in a state of maceration. Upon 
the palms and soles the secretion is continually oozing out 
in drops, frequently in such quantity as to be dripping wet. 
It is ordinarily seen to come from the whole surface. The 
flow is usually a steady one, although influenced by the 
general condition, the state of the nervous system, and the 
surrounding temperature. The skin cannot be kept dry, 
becoming wet again in a few minutes after having been 
dried; it is observed to be of a whitish or yellowish color, 
and to have a soggy appearance. 

Upon the soles the affection is even more distressing than 
on the palms, for the socks and shoes become so saturated 
with moisture as to be constantly wet. The maceration of 
the epidermis, together with the secretion about the toes, 
gives rise to a disagreeable odor, which, in spite of frequent 
washing, is difh'cult to remove. The epidermis becomes 
soaked and macerated, peels off, and leaves the tender skin 
exposed. The pain attending walking when in this con- 
dition is often severe, and patients at times are obliged to 
remain off their feet. 

There are all grades of sweating of the palms and soles, 
as upon other regions, but in almost all cases it is sufficient 
to give rise to serious inconvenience. 

The genital organs are also sometimes the seat of hyperi- 
drosis, particularly in men. The scrotum and perineum are 
commonly attacked, and occasion symptoms similar to those 
just mentioned in connection with the palms and soles. 

The disorder may continue for a short time only or it may 
last for years ; very often it is extremely obstinate. Erythema 
and intertrigo are apt to accompany it, especially when it 



HYPERIDROSIS. 127 

occurs about surfaces that naturally come in contact, as about 
the genital organs, nates, fingers, and toes. 

Etiology. — The causes are in the majority of instances not 
to be determined. It affects the cleanly as well as the 
uncleanly; females as well as males; the young as well 
as the old; and is observed in the healthy as well as in the 
feeble. 

There can be no doubt, however, that faulty innervation 
plays an important part in its causation, this origin being 
one frequently recognized in clinical experience. The com- 
plaint is always aggravated by a high temperature, and is 
consequently worse in summer than in winter. 

Pathology. — The affection is a purely functional one, con- 
sisting in an abnormal secretion of the sudoriparous glands. 
Owing to the increased activity of the glands, and to other 
causes, hyperemia may take place. It will here be remem- 
bered that an extensive plexus of vessels surrounds each 
sweat gland, which, under certain circumstances, may be- 
come the seat of congestion. 

The secretion in hyperidrosis differs chemically in no way 
from normal sweat. 

Diagnosis. — This is never attended with any difficulty ; at 
the same time it is of importance to distinguish hyperidrosis 
from other disorders of the sudoriparous glands which are 
accompanied by increased secretion and inflammation, as, 
for instance, prickly heat. Oily seborrhcea can scarcely be 
mistaken for hyperidrosis. 

Treatment. — If there be debility or faulty innervation, a 
general tonic treatment is to be ordered. Iron, strychnine, 
quinine, the mineral acids, and similar remedies are to be 
employed, together with every measure which will tend to 
promote the health of the patient. Ergot has been used 
with good result. The condition of the nervous system is 
to be carefully investigated, and, if in any way impaired, 
should receive special attention. Faradization has been 
used with success in some cases. Exciting causes, as high 
temperature, are always to be avoided. 

Local treatment is of great benefit in all forms of hyper- 
idrosis. Water is to be employed as seldom as possible. 



128 DISORDERS OF SECRETION. 

Ordinary baths are not to be allowed. The parts should be 
cleansed with a wet cloth and immediately dried with lint or 
a towel. Various dusting powders, as starch and powdered 
French chalk, may now be used, and removed as fast as they 
become wet and caked. The parts are to be protected from 
irritating influences, and especially from friction. Lotions 
containing alcohol and astringents are to be recommended. 
Alcohol alone may often be used with marked benefit. The 
following prescription will be found of value: 

R Acidi Ttinnici, ^i ; 

Alcoholis, f^viii. 
M. — Sig. Use as a lotion. 

Various other astringents may also be employed, such as 
sulphate of zinc and alum; also salt baths. Frequent wash- 
ing of the parts with dilute ammonia water has been well 
spoken of; acetic acid, diluted, will also be found serviceable 
in checking mild forms of the disorder. 

In hyperidrosis of the palms and soles the following oint- 
ment, esteemed by Wilson, may be prescribed, the parts being 
first well washed with carbolic acid or juniper-tar soap. 

R Ungt. Picis liquidse, 

Ungt. Sulphuris, aa £i. 
M. Ft. ungt. 
Sig. To be spread upon cloths and applied with a bandage. 

For obstinate cases, however, the treatment about to be 
described will be found of greatest service.* It is abso- 
lutely necessary to its success that its various steps be closely 
followed and properly carried out. The parts are to be 
cleansed with water and soap, and the following ointment 
applied : 

R Emplast. Diacbyli, giv ; 

Olei Olivae, f ^iv. 
M. Ft. ungt.f 
Sig. To be used on cloths. 

Pieces of muslin or cotton cloth are to be cut to the size 

* This method of treatment was first introduced to the profession by Hebra. 
f The plaster to be melted, and the oil added and stirred until a homo- 
geneous mass results. 



BROMIDROSIS. 129 

of the parts, and the ointment spread on thickly and applied. 
Lint smeared with the ointment is also to be placed between 
the toes or lingers, so that every portion of the skin may be 
completely covered with a layer of the ointment. These 
dressings are to be bound down closely by means of a 
bandage. 

The cloths are to be changed after having been on twelve 
hours, when the parts are not to be washed, but simply 
rubbed dry with lint and a starch dusting powder, after 
which new dressings are again to be applied in exactly the 
same manner. This proceeding is to be repeated every 
morning and evening, and continued for from one to two 
weeks, according to the severity of the case. Even when 
the disease is upon the soles, the patient may be permitted 
to walk about in loose shoes. At the expiration of eight 
or ten days the parts are to be rubbed with the dusting 
powder and the dressings discontinued. The powder should 
be used for several weeks longer. Usually the sweating 
tends to lessen and gradually disappear, after two or three 
weeks from the beginning of the treatment. A repetition 
of the course, in severe cases, is at times necessary before 
bringing about a complete cure. The relief obtained is 
generally permanent. For slight cases of hyperidrosis some 
of the stimulating toilet soaps, containing sulphur, juniper- 
tar, or carbolic acid, may be employed. 

Prognosis. — This should be guarded. Many cases are easily 
relieved, while others are extremely intractable. The state 
of the health, the duration and locality of the disease, as well 
as its extent, are all to be considered. Lastly, the ability of 
the patient to follow the treatment and necessary directions, 
must greatly influence the result. 

BROMIDROSIS. 

Si/n. Osmidrosis. 

Bromidrosis js a functional disorder of the sweat glands 
characterized by more or less sweating and an offensive odor. 

Symptoms. — The secretion may be normal or abnormal as 
regards quantity. It may occur either as a universal or as 
a local disorder. 



130 DISORDERS OF SECRETION. 

When universal, the patient is noted to exhale a peculiar, 
heavy, disgusting odor from the whole surface, which is 
always intensified with increased perspiration. It may have 
a distinctive character, which may be likened, for example, 
to the odor of a goat (odor hircinus) or urine, or it may be 
simply strong-smelling. It occurs as an independent affec- 
tion, and also, to some extent, in connection with various 
systemic diseases, particularly the exanthemata. 

The local forms are more frequently encountered. Certain 
regions of the body, as the axillse, genitalia, perineum, and 
feet, are the usual seats of this disorder. The intensity of 
the odor varies, being at times merely heavy or strong, and 
in other instances so powerful, penetrating, and offensive as 
to bauish the individual from all society. Bromidrosis of 
the feet is the most common local form, and constitutes a 
very troublesome and truly disgusting disease. The emana- 
tions here are intensified by the perspiratory secretion acting 
upon the normal sebaceous matter, producing a smell particu- 
larly foul. Owing to the warmth and moisture which always 
exist about these parts, the scent is exceedingly persistent. 
The disease is very similar to hyperidrosis, the main differ- 
ence at times being in the quality of the secretion. 

Treatment. — The treatment should be the same as that 
recommended for hyperidrosis. 

CHROMIDROSIS. 

CHROMIDROSIS IS A FUNCTIONAL DISORDER OF THE SWEAT GLANDS 
IN WHICH THE FLUID POURED FORTH IS VARIOUSLY COLORED. 

Symptoms. — In this affection the secretion of sweat is 
usually excessive and possesses positive color; it may be 
bluish, blackish, reddish, greenish, or yellowish. It consists 
in an oozing. of sweat, more or less profuse, which is observed 
to come directly from the openings of the ducts. The fluid 
possesses the properties of normal sweat, and in addition the 
peculiar coloring matter. 

The disease is a very rare one. It occurs most commonly 
in women, and is much more frequent in unmarried than in 
married women. It is usually encountered in connection with 



ANIDROSIS. 131 

serious uterine disorders of one kind or another. Various 
regions may be attacked, but it has been noted more fre- 
quently upon the face, chest, abdomen, arms, hands, and 
feet. 

The amount of secretion may be very slight or excessive 
in quantity. As a rule, the flow is not constant, but appears 
suddenly, remains for a short time, and then disappears 
again. It may come and go in this manner for a period of 
weeks or months. It is usually brought on by excitement, 
emotion, or pas3ion, although it may appear without any 
exciting cause. 

Pathology. — The disease is accounted for by a chemical 
alteration of the secretion, caused by the presence in the 
system of some abnormal coloring matter, which thus finds 
its vent from the body. Prussian blue, copper, and other 
similar substances have been detected by analysis in the 
sweat, to which the color is due. 

Treatment. — The treatment is to be directed against the 
general condition of the patient, which will usually be found 
to be one of chlorosis, anaemia, debility, or nervous prostra- 
tion. It should be similar to that referred to in considering 
hyperidrosis. 

ANILROSIS. 

Anidrosis is a functional disorder of the sweat glands 
consisting in a diminished and insufficient secretion of sweat. 

It is the opposite of hyperidrosis. It occurs in the course 
of certain chronic diseases of the skin, and is particularly 
noticeable in ichthyosis; the same condition may be ob- 
served in patches of eczema, psoriasis, and in elephantiasis 
Grsecorum. It may also exist as the result of a congenital 
deficiency of the sweat glandular apparatus, in which case 
the person perspires very slightly, and perhaps sensibly only 
under a high temperature. 

There are other cases in which the individual ceases at 
times to sweat. In these instances the health is more or 
less impaired, and serious symptoms often arise, especially 
during the warm weather. It is at this season that such 
cases are apt to come under observation. Occurring as an 



132 DISORDERS OF SECRETION. 

independent disorder, it is rare. I recall meeting, two sum- 
mere ago, the case of a man — a blacksmith — who suddenly, 
during the hot weather, ceased sweating. He was, when I 
saw him, several weeks after the trouble first manifested 
itself, unable to pursue his occupation, and complained 
greatly of indisposition, headache, and other symptoms of 
distress. 

Treatment. — Every means should be instituted to promote 
the activity of the skin and restore the function of the 
glands. Hot baths should be ordered, with frictions; the 
steam bath, in moderation, especially is to be recommended. 
Cold baths, accompanied with rubbing by means of coarse 
towels, will also be found of service. Exercise is to be 
freely indulged in, and the general health looked after in 
every way. 

SUDAMINA. 

Syn. Miliaria Crystallina (Hebra). 

SlJDAMINA IS A NON-INFLAMMATORY DISORDER OP THE SWEAT 
GLANDS, CHARACTERIZED BY PIN-POINT OR PIN-HEAD SIZED, TRANS- 
PARENT, WHITISH VESICLES, UNATTENDED WITH ITCHING. 

Symptoms. — The vesicles are discrete, but crowded together 
in very great numbers, and may exist upon any portion of the 
body; they have preference, however, for the neck, chest, and 
abdomen, and other regions of the trunk. They are some- 
what raised above the level of the surface, and may be felt 
as slight elevations. In appearance they resemble minute 
drops of free sweat. They are whitish or pearl-colored. 
They form quickly, and soon assume their definite size, 
which does not change throughout their course ; they may 
last for several days or longer. Fresh crops may from time 
to time be developed. 

The vesicles are always discrete; they never run together; 
their contents never become puriform ; nor do they ever 
rupture. The fluid is reabsorbed, and the covering, desic- 
cating, forms a thin, delicate membrane, which passes away 
in the form of slight desquamation. 

Etiology. — The cause of sudamina may almost always be 
found in some constitutional or febrile disease. The dis- 



SUDAMINA. 133 

order is of quite frequent occurrence in tuberculosis, typhus 
and typhoid fevers, acute articular rheumatism, and puerperal 
fever. It is invariably caused by high temperature, provoking 
unusual activity of the glands. At times the vesicles are seen 
independent of free perspiration. 

The affection is common during the hot weather, and is 
ordinarily observed in those whose skins are delicate. It 
occurs both in children and in adults. The general condi- 
tion of the patient exerts a strong influence in favor of or 
against the production of the complaint. Their presence is 
to be considered as a sign of general debility. 

Pathology. — The affection originates in disturbance of the 
sweat glands. The glands become excited beyond their 
capacity for normal excretion, and, in place of the fluid 
finding its outlet upon the surface, from some cause it col- 
lects between the layers of the epidermis. It is in this 
manner that the vesicles are formed, as demonstrated by the 
anatomical researches of Dr. Haight, of New York.* 

* Sitzungsberichte der Kais. Acad., "Wien, 1868. 



CLASS II. 
HYPEREMIA— HYPEREMIAS. 

In this class are arranged those disorders which are char- 
acterized by the presence simply of an abnormal quantity of 
blood in the vessels supplying the skin. The condition may 
arise from a number of causes, and occasions various appear- 
ances upon the surface. 

The hyperseniic affections possess the following features. 
Redness of the skin is constant, and is present in all degrees 
of color, from pink or light red to dark red ; it disappears 
upon pressure, but is seen to return instantly. The tem- 
perature of the part is usually elevated. The seat of the 
disorder is noted to be in the superficial portions of the 
skin, either in the papillary layer or in the main body of the 
corium. The hyperemias occur in a variety of forms or pat- 
terns, usually without definite shape; they may be the size 
of a small coin, or as large as the palm of the hand and 
even larger. Their course is for the most part acute ; they 
often last but a few hours or days; in other cases they 
continue for a longer period. Slight itching or burning 
sensations at times accompany them. 

Hyperemias may be classified into active and passive. Both 
forms may, further, very properly be divided into those which 
are idiopathic and those which are symptomatic. 

Idiopathic Active Hyperemias are, in a strict sense, local 
affections. They include those disorders occasioned by the 
direct application of irritating agencies to the skin. 

Symptomatic Active Hyperemias are, on the other hand, 
due to general disturbance of the system, which usually has 

134 



ERYTHEMA SIMPLEX. 135 

its- chief seat in some region of the body distant from the 
skin. 

Idiopathic Passive Hyperemias are due to external causes ; 
they comprise the various so-called lividities of the skin. 
Mechanical causes, in the form of severe or continued press- 
ure upon the skin; direct obstruction to the circulation, 
produced by bandages, articles of dress, etc., and cold, may 
be referred to as the most frequent sources of this kind of 
hyperemia. 

Symptomatic Passive Hyperemia occurs in those cases 
where there is some imperfection in the function either of 
the circulation or of the respiration. It manifests itself by 
a more or less general bluish or purplish discoloration of the 
skin ; it is seen, for example, in cyanosis. 

ERYTHEMA SIMPLEX. 

Erythema simplex is a hyper^emic disorder characterized 
by redness, occurring in the form of variously sized, dif- 
fused or circumscribed, non-elevated patches, irrespective 

OF CAUSE. 

Symptoms. — It consists in a congested state of the skin, 
marked by the symptoms which have been already enumer- 
ated as belonging to the hyperemias. 

The causes which give rise to simple erythema are numer- 
ous, and are, moreover, diverse in their nature; they com- 
prise heat, cold, injuries, poisons aud irritating substances 
of all kinds, certain systemic diseases, disorders of internal 
organs, as of the alimentary canal, etc. 

Erythema may be idiopathic or symptomatic. 

IDIOPATHIC. 

Erythema from Caloric. — Under this head are included 
the erythemas occasioned by heat and cold. Both of these 
agencies, at certain temperatures, bring about simple conges- 
tion of the skin ; carried beyond this temperature they pro- 
voke exudation from the vessels or inflammation. Artificial 
heat, the rays of the sun, etc., are among the well-known 
and commoner causes of this form of erythema. 

Erythema from Traumatism. — Simple erythema may also 



136 HYPEREMIAS. 

be occasioned by traumatism, as, for example, continued 
pressure, rubbing, etc. It is observed as the result of tightly- 
fitting garments, bandages, trusses, etc. 

Erythema from Poisons. — Poisons of all kinds play a very 
important part in the production of erythema. Many sub- 
stances, both mineral and vegetable, act injuriously upon the 
skin. A few of these, as mustard, sulphur, arnica, various 
dye-stuffs, acids, and alkalies, maybe mentioned as frequently 
giving rise to cutaneous disturbance. 

SYMPTOMATIC. 

Here are to be placed all those simple erythemas, or rashes, 
which occur in the course of certain systemic diseases or as 
the result of some internal derangement. They may occur 
upon any portion of the body, commonly upon the trunk. 
A knowledge of these erythematais extremely necessary, for 
they frequently simulate, and may be mistaken for, other 
more serious affections. 

Simple erythemas due to disorders of the internal organs, 
as the stomach and bowels, are of very frequent occurrence 
in infants and young children. They may assume various 
markings and patterns, .and may be either slight or well 
defined in their expression. At times they are persistent; 
in other cases they dispose to relapse from time to time. 

Roseola. — Certain general diseases are at times accom- 
panied with hyperemia of the skin, which shows itself in the 
form of roundish spots, the size of a pea or finger-nail, to 
which the term Roseola has been given. It denotes simply 
the peculiar form of the erythema; it in no degree indi- 
cates the nature of the disease which has brought it forth. 
Thus, roseola is employed to express one of the first lesions 
of syphilis upon the skin, and also the erythema which is 
sometimes observed in connection with vaccinia, or with 
variola. 

Diagnosis.— From what has been said it is manifest that 
the boundary line between simple erythema and dermatitis 
—simple inflammation of the skin — is very frequently ill 
defined. As stated in considering the subject of hyperemia, 
in connection with the general pathology of the skin, it is 



ERYTHEMA INTERTRIGO. 137 

often difficult to determine exactly when exudation com- 
mences ; clinically, however, no trouble of this character 
presents itself, for the subjective symptoms in particular, 
in affections attended with exudation, are so decided as to 
permit of no doubt concerning the pathological change. 

Treatment. — This must obviously depend upon the nature 
of the erythema, with special reference to the cause. 

The idiopathic erythemata require nothing beyond the 
removal of the cause, which is in all instances sufficiently 
patent. In cases of persisteut symptomatic erythema, such 
as are of common occurrence in infants, the internal disorder 
to which the cutaneous manifestation is due must be sought 
for, and at once relieved, if possible. 

Local applications, where they are demanded, should be 
employed as the case under consideration may require; for 
this purpose the various bland dusting powders, soothing 
ointments, and similar preparations, may be used. 

ERYTHEMA INTERTRIGO. 

Erythema intertrigo is a hyper^emic affection character- 
ized BY REDNESS, HEAT, AND AN ABRADED SURFACE WITH MACERA- 
TION OF THE EPIDERMIS. 

Symptoms. — It occurs chiefly in those parts where the 
natural folds of the skin come in contact with one another, 
as about the nates, perineum, groins, axillse, and beneath 
the mammye, and is produced by the friction of two opposing 
surfaces. It is especially common in fat persons, and in 
infants whose skins are tender. The skin becomes chafed, 
and feels hot and sore. 

Perspiration, also, at times takes place, which, acting 
upon the epidermis, macerates it and gives rise to an acrid, 
mucoid fluid. If the process be not speedily arrested at this 
stage, symptoms of inflammation may appear; a simple ery- 
thema intertrigo may pass into a dermatitis. 

It makes its advent suddenly, and, unless checked by the 
removal of the cause, soon becomes intensely annoying to 
the patient ; properly managed in its early stage, it ordina- 
rily passes away as rapidly as it came. It may last but a 
few hours, or, on the other hand, it may continue for weeks. 



[88 HYPEREMIAS. 

Occurring between the nates, its common seat, it is usually 
troublesome, and may prevent walking, or even sitting. It 
is apt to be more or less persistent in infants; with proper 
care and treatment, however, it rarely causes serious annoy- 
ance. The disorder is hyperaemic in its nature, and always 
disappears without leaving trace of its former existence; it 
is liable to relapse. 

Etiology. — It is for the most part an affection of hot weather, 
although it may occur in winter if sufficient cause be present; 
it is seen at all seasons of the year in young infants. 

It may be either idiopathic or symptomatic in its origin. 
Unusual exercise, sedentary habits, sitting for a long time 
on cushioned seats, excessive underclothing, and other con- 
ditions which occasion more than usual warmth of the body, 
all favor its development. The cause is always to be found 
in an undue amount of heat about the parts affected, arising 
either from friction or from permitting the opposing surfaces 
exposed to warmth to remain for some time in contact with 
each other. In children, and in those wmose skins are par- 
ticularly delicate and sensitive, simple rubbing, as from a 
garment, may be sufficient to cause an erythematous inter- 
trigo. This is often observed in the newly born. 

In infants, as in the case of symptomatic simple erythema, 
the cause may not infrequently be found in stomach or 
bowel derangements, worms in the alimentary canal, teeth- 
ing, and in other general disorders. 

Treatment. — As a rule, very little is required beyond ordi- 
nary care and attention. It is, of course, essential that the 
exciting cause be suspended. The parts should be washed 
with cold water and castile soap, and dried with a soft rag 
or towel ; they are usually quite sensitive. This operation 
should be repeated from time to time as may seem indi- 
cated. The folds of the skin are to be separated and kept 
apart with lint or with a piece of linen cloth. Dusting 
powders constitute the best topical remedies; they may be 
prepared with starch, together with oxide of zinc, French 
chalk, and similar substances, in varying proportions, as, 
for example, in the following : 



ERYTHEMA INTERTRIGO. 139 

R Pulv. Oxidi Zinci, 31 ; 

Pulv. Amyli, sjvii. 
M. — Sig. Dusting powder. 

Ill cases which prove obstinate I am in the habit of using 
lotio nigra as an application. Applied once or twice a day, 
followed by the use of some bland powder, as the above, it 
is certainly a very efficacious remedy. Dilute alcoholic lo- 
tions may also at times be employed. Astringent lotions, 
composed of alum or sulphate of zinc, a few grains to the 
ounce, prove serviceable in rebellious cases. 



CLASS IIL 
EXSUDATIONES— EXUDATIONS. 

The exudations, or exudative diseases, constitute by far 
the largest and most important group of the diseases of the 
skin. They include all those affections which are charac- 
terized by inflammation. 

In this class are to be found urticaria, eczema, psoriasis, 
acne, and a number of other common diseases, with which 
the physician finds himself in daily contact. 

The various affections are exceedingly diverse as regards 
their external form and character; some manifesting them- 
selves as erythema; others as papules, vesicles, pustules, and 
blebs, together with their secondary products, scales, crusts, 
etc.; while yet another class appear as diffused, more or less 
deep-seated inflammations, involving not only the skin, but 
also the subcutaneous structures. 

The exudations vary extremely as to their course; some 
are acute, and terminate in spontaneous recovery; while 
others, the majority, incline to become chronic, and to con- 
tinue indefinitely. 

Some are simple and benign in their nature; others are 
most distressing to the patient, and at times serious in their 
consequences. Their causes are manifold; in many cases 
they are singularly different. Their pathological features 
alone entitle them to be grouped into one class; these have 
been already considered in connection with the subject of 
general inflammation. 

140 



ERYTHEMA MULTIFORME. 141 



ERYTHEMA MULTIFORME. 

Erythema multiforme is an acute, exudative disease, char- 
acterized BY REDDISH OR PURPLISH MACULES AND PAPULES, OC- 
CURRING EITHER ISOLATED OR IN PATCHES OF VARIOUS SIZE AND 
CONFORMATION. 

Symptoms. — The disease is usually marked by the variety 
of its lesions, which manifest themselves either as erythe- 
matous patches or as papules, vesico-papules, and tubercles. 
When patches occur, they are apt to be of the most varied 
shapes and sizes. The peculiarities of configuration which 
the lesions assume have given rise to the terms annulare, iris, 
and marginatum, in connection with the disease, according 
as they happen to represent one or another of these forms. 

When the patch is circular in form, fading in the centre 
as the disease extends to the periphery, it is termed ery- 
thema ANNULARE. 

Occasionally a series of concentric rings are formed, 
possessing beautifully variegated colors, made up of red, 
purple, yellow, blue, etc. ; when this takes place it is 
designated erythema iris. 

At times the patches, after spreading over a considerable 
surface, gradually fade in the centre, and terminate with a 
sharply-defined border, the disease consisting at this stage 
simply of serpentine lines or bands; this form is known as 

ERYTHEMA MARGINATUM. 

In place of an erythematous patch, the disease very fre- 
quently appears in the form of distinct papules and tubercles, 
which occurrence has given rise to the names erythema 
papulatum and erythema tuberculatum. The former of 
these varieties is that in which the affection is commonly en- 
countered. It consists of isolated or aggregated flat papules, 
variable as to size and shape. They are either bright red 
or purplish in color; disappear in part under pressure, and 
seldom last longer than a few days or a week. Erythema 
tuberculatum is to be viewed simply as an exaggeration of 
the papular form of the disease. 

All of these varieties are but different forms and stages of 
one process. In a given case it is not rare to see several, if 



142 EXUDATIONS. 

not all, of these manifestations. They frequently, and inJ 
deed commonly, run into one another. It is this protean 
character of the lesions that has given rise to the name by 
which the affection is known, — erythema multiforme. 

The course of the disease is an acute one; it may con- 
tinue for a few days or for two or three weeks, at the end 
of which time it disappears spontaneously, leaving, perhaps, 
slight pigmentation and desquamation. During its course 
new crops of lesions are apt to develop, appearing from time 
to time in the place of those which have faded away. The 
process is often quite ephemeral in character. 

It attacks certain regions of the body in preference; the 
backs of the hands and feet, and the arms and legs, are the 
localities where it is commonly seen. The hands and fingers 
are its most common situation. It usually occurs symmetri- 
cally. It may also show itself about the face, especially the 
forehead, in the form of macules and papules; also upon 
the trunk. 

The subjective symptoms are seldom troublesome ; there 
is, as a rule, but little itching and burning, notwithstanding 
the angry look which the eruption ordinarily assumes. The 
temperature is not increased to any extent. Symptoms of 
general disturbance may or may not accompany the com- 
plaint; not infrequently malaise, headache, rheumatic pains, 
and gastric derangement are present. It is seen for the most 
part in early adult age. 

Etiology. — The affection is peculiar in that it makes its 
appearance almost exclusively during the spring and autumn 
seasons. It is also seen, exceptionally, at other periods of 
the year.* 

The causes are at times obscure. The papular form, how- 
ever, is not infrequently called forth by derangement of the 
stomach ; in these cases it is observed to run a course some- 
what similar to that of urticaria. It is at times accompanied 
with rheumatism, and in some instances bears a resemblance 

* For further information upon this and other points of interest relating 
to the disease, see a report by Lipp, of Graz, Archiv fur Dermatologie und 
Syphilis, vol. iii. p. 221; also an able article by Moriz Kohn (Kaposi), in the 
same journal, vol. iii. p. 381. 



ERYTHEMA MULTIFORME. 143 

to purpura rheumatica. It occurs in both sexes, but is more 
common in the female. 

Pathology. — It must be classed with the exudative affec- 
tions, occupying a position by the side of urticaria, with 
which it possesses at times certain points in common. The 
close relationship between it and herpes iris has long been 
recognized; the latter disease is but an advanced stage of 
erythema iris. Up to the point of vesiculation it is an 
erythema multiforme, while beyond this stage it is called 
herpes iris. They are, notwithstanding their usual separa- 
tion (which rests purely upon anatomy), one and the same 
process. Of the morbid anatomy of the lesions nothing defi- 
nite is known. 

Diagnosis. — When the peculiar appearance and acute course 
of the lesions, together with their multiform character, are 
borne in mind, no difficulty should occur in the diagnosis. 
The absence of all violent itching or burning sensations will 
serve to distinguish it from urticaria, the affection to which 
it bears closest resemblance. It differs from urticaria also 
in that the eruption is usually more pronounced in charac- 
ter, is of a more decided color and form, and is more per- 
sistent in its course. Wheals are never present in typical 
erythema multiforme. 

From eczema papillosum it is to be distinguished by the 
absence of severe itching, and by the large size of the 
papules, as well as their irregular shape and form. 

The difference between herpes iris and erythema iris 
being one only of development, they are often seen to merge 
into each other; the diagnosis here would be one simply 
concerning the name. If there were no vesicles present, it 
would be termed an erythema; while, if these had formed, 
the term herpes would be employed. 

Erythema nodosum is to be diagnosed from erythema 
multiforme by its prominently raised, rounded, firm tumors 
or nodes, which occur for the most part on the extremities, 
and, in particular, along the line of the tibiae. 

Treatment. — In the majority of cases no active treatment 
is called for. If derangement of the alimentary canal exist, 
it is to be corrected by appropriate means. The bowels 



144 EXUDATIONS. 

should be opened by a mild saline laxative, which may be 
repeated from time to time during the attack. The diet 
should be light, all stimulating articles of food and drink 
being avoided. 

The local applications should be of the simplest character. 
Lotions of equal parts of alcohol and water, or of carbolic 
acid, a drachm to the pint of water, will be found useful 
where there is itching. Dusting powders of starch and 
oxide of zinc, equal parts, are of service in protecting the 
inflamed surface. 

Prognosis. — The affection runs a spontaneous course towards 
recovery. With or without treatment, it usually terminates 
in a week or two without leaving any trace of its former ex- 
istence, except occasionally slight pigmentation and desqua- 
mation. It is a benign disease. Kelapses are very liable to 
recur from year to year. 

ERYTHEMA NODOSUM. 

Syn. Dermatitis Contusiformis ; Fr. Erytheme Noueux. 

Erythema nodosum is an acute, exudative disease, char- 
acterized BY THE FORMATION OP ROUNDED OR OVAL, VARIOUSLY- 
SIZED, FIRM, PURPLISH NODULES. 

Symptoms. — The disease is apt to be ushered in with some 
slight disturbance of the system. The nodules make their 
appearance quite suddenly, and may exist upon various 
regions of the body, although they have very decided pref- 
erence for the legs, arms, and face. They vary in size from 
a small nut to an egg; are oval or rounded in shape; and 
are prominent and usually well defined in outline. In color 
they are reddish or purplish, becoming darker as they grow 
older. At times they are quite livid. As they disappear 
they often assume a yellowish tint. They have a shining, 
tense look, as though suppuration were about to take place; 
this process, however, never occurs, for they invariably 
result in reabsorption. To the touch they are firm, -or even 
hard, but they become softer as they are about disappear- 
ing. In number they may vary from a few to dozens; they 
may occupy the legs only, or various regions of the body at 
the same time. 



ERYTHEMA NODOSUM. 145 

As a rule, they do not all appear at once, but come out at 
intervals in the form of crops, accompanied by febrile symp- 
toms. They are painful, and tender on pressure, but are not 
attended by itching sensations. 

The affection terminates in spontaneous recovery; it is 
seldom noted to last more than two or three weeks. 

Both sexes are attacked. It is more frequent in females. 
It commonly occurs in early adult life. 

Etiology. — The causes of this peculiar and quite rare dis- 
ease are by no means well understood. 

Loss of appetite, languor, and other symptoms of mal- 
aise, often precede the outbreak of the nodules. Eheu- 
matic pains are also very frequently present, both before 
and during the attack. Digestive derangements, as well as 
other functional disturbances, have been noted in connection 
with its appearance. 

Like erythema multiforme, to which disease it is very 
closely allied, it usually shows itself in the spring and 
autumn. 

Pathology. — Its exact nature is involved in uncertainty. 
It is an exudative process, similar in character to erythema 
tuberculatum, but at the same time possesses such marked 
points of difference as to constitute a separate affection. 
Hebra* appears to think that, in some cases at least, it is 
essentially an inflammation of the lymphatics, the nodules 
being frequently observed seated on the course of these 
vessels. But, as Hebra himself states, this view does not 
hold good for all cases met with. Bohnf is of the opinion 
that each tumor is an inflammatory infarction, caused by 
embolism in the cutaneous vessels; he consequently regards 
the affection as being closely allied to purpura rheumatica, a 
view to which I incline. It presents, certainly, many points 
in common with this variety of purpura. In some cases the 
exudation is of a serous character, but in most instances it is 
hemorrhagic. The process varies in intensity. 

Diagnosis. — It is not to be mistaken for the result of external 

* Diseases of the Skin, vol. i. p. 291, New SyJ. Soc. translation. London, 
1868. 
f Jahrbuch fur Kinderheilkunde, Heft 4, 1868. 

10 



146 EXUDATIONS. 

violence. The swelling? bear a close resemblance to bruises, 
and may readily be confounded with injuries of this kind. 

The disease also simulates erysipelas, especially if it occur 
about the lace, but may be distinguished from it by the 
presence of distinct and isolated nodules, which are, more- 
over, firm to the touch. 

The tumors at times resemble threatening abscesses; but 
their previous history, number, situation, and course will 
always serve to characterize them. They can scarcely be 
confounded with furuncles. The affection maybe diagnosed 
from erythema multiforme by the presence of the circum- 
scribed, hard, prominent nodules. 

Treatment. — No very active treatment is called for, inas- 
much as the complaint always ends in spontaneous recovery. 
When symptoms of functional derangement are present, I 
they should be corrected. The bowels are very apt to be 
constipated, and are best relieved by a saline laxative. The 
natural mineral waters may be prescribed with advantage. 
The condition of the stomach should be investigated ; if 
disordered, a simple diet should be ordered, together with 
such remedies as may seem proper. In females, the prepara- 
tions of iron are often given with benefit. Quinine may also 
be directed. If the affection be extensively developed upon 
the lower limbs, rest and the recumbent position should 
always be enjoined. 

Local applications are of little avail ; warm fomentations, 
however, are at times useful in affording relief when the parts 
are painful. Strong applications should never be employed. 

Prognosis. — This is always favorable. The trouble seldom 
lasts more than a few weeks. At times it is more persistent. 
Helapses may occur. 

URTICARIA. 

Syn. Nettle-rash: Febris Urticata : Germ. Xesselausschlag: Fr. Urticaire] 
Urticaria is an acute, exudative affection, characterized I 

BY THE DEVELOPMENT OF WHEALS OF A WHITISH OR REDDISH COLOR, 
ACCOMPANIED BY STINGING, PRICKING, TINGLING SENSATIONS. 

Symptoms. — The disease shows itself by the sudden forma- 
tion of wheals, of variable size, shape, and color. 



URTICARIA. 147 

They vary greatly as to size; at times they are no larger 
than a split pea, while in other instances they occupy ex- 
tensive tracts of the surface; ordinarily, they are finger-nail 
sized. They may occur as circumscribed, isolated efflores- 
cences, or in the form of patches, caused by a number of 
the lesions having coalesced. All large patches are formed 
in this manner. Wheals likewise vary exceedingly as to 
shape; they are usually roundish or oval, but may exist in 
an endless number of forms. Lines, streaks, crescents, and 
irregularly-shaped patches, may all in turn be assumed. At 
times the configuration is quite grotesque. They are ob- 
served either as very slight elevations, barely perceptible 
above the level of the skin, or as raised prominences several 
lines or more in height. To the touch they may be soft 
or quite hard. In color they are whitish, pinkish, or red- 
dish, and at times variegated or streaked. They are com- 
monly surrounded by an areola. Xo trace follows their 
disappearance. 

The subjective symptoms are intense burning, tingling, 
stinging sensations, likened to the sting of the nettle. They 
may be simply very annoying, or, on the other hand, ex- 
ceedingly distressing. The patient impulsively scratches, 
which, though it in part relieves the disagreeable sensation, 
always causes more of the efflorescence to appear. 

Urticaria is the most ephemeral of cutaneous diseases. 
Its advent is always remarkably sudden, a few minutes not 
infrequently sufficing for its full development; it may re- 
main upon the surface for but a few moments, or for an 
hour or longer. Even while the eruption is out, individual 
wheals are extremely fugitive in their character, coming 
and going in a most arbitrary manner. The disease often 
leaves one portion of the body to show itself in a remote 
part; it may also repeatedly change its location, shifting its 
seat from time to time without apparent cause. All regions 
of the body, including the scalp, are liable to its attacks; 
the whole surface or only a part may be invaded. It has no 
regions of predilection, but is apt to occur upon those parts 
which are subject to pressure or hyperemia from the con- 
tact of the clothes. It occurs at all periods of life, and 



148 EXUDATIONS. 

attacks both sexes in about equal proportion. Children are 
particularly subject to it. 

It is ordinarily an acute disorder, lasting but a few hours 
or days, during which time frequent exacerbations may take 
place. Its duration depends entirely upon the presence or 
the removal of the exciting cause. It may also occur as a 
chronic affection, the relapses taking place with such fre- 
quency, and extending over so long a period, as to warrant 
the use of the term chronic. 

There are several varieties of urticaria, named according 
to peculiarities in the conformation of the anatomical lesion, 
which call for particular description. 

Urticaria Papulosa. — This is a variety of the disease 
which, on account of its peculiar character and frequency, 
calls for special remark. It is also known as lichen ur- 
ticatus. 

Here the lesion possesses the form of a papule with all of 
the characteristics of a wheal. It is observed particularly in 
young children, and shows itself as pin-head or split pea 
sized, acuminated papules, which appear suddenly, and, after 
continuing hours or days, slowly disappear. They usually 
occur in a dispersed manner over the body, and are rarely 
seen in great numbers. They are attended with intense 
itching. Owing to the scratching of the patient, their apices 
are always more or less torn, and become covered with a 
slight blood crust. The disease is most annoying at night. 
The children in whom this form of urticaria is noted are, 
as a rule, badly cared for and improperly nourished. The 
affection is common among the poor, especially those who 
live in squalor. 

Urticaria is of not infrequent occurrence in the course 
of other diseases. It is necessary, therefore, to distinguish 
those cases in which it is the sole disorder and those in 
which it exists as a secondary affection. It is seen as a com- 
plication in several diseases, and often plays such an active 
part as quite to overshadow the primary lesion. 

Purpura is sometimes the seat of urticaria, a mixed lesion 
resulting, half hemorrhage and half wheal, whereby the 
presence of the hemorrhage is often obscured. The urtica- 



URTICARIA. 149 

rial element, however, is observed to be secondary. This 
occurrence has given rise to the terms urticaria hemor- 
rhagica, and purpura urticans or urticata. 

A disposition to the formation of bullae is now and then 
observed in connection with urticaria, producing an erup- 
tion partaking of the nature of both blebs and wheals. 
When this occurs the wheals form first, but are displaced by 
blebs, which assume all of the characteristics of the bullae 
of pemphigus. This peculiar and quite rare combination of 
symptoms has occasioned the term urticaria bullosa. The 
disease, however, should, I think, be viewed rather as a 
variety of pemphigus than as an urticaria. 

Acute Urticaria. — According to the cause, will the dis- 
ease make its appearance in one way or another. It is, 
however, usually ushered in with febrile symptoms, accom- 
panied by languor, headache, depression, gastric derange- 
ment, furred tongue, and other signs of systemic disturb- 
ance. The efflorescence appears suddenly, so that in an 
hour's time the whole body may be more or less invaded. 
In other cases only a portion of the body, as the face, the 
trunk, or the limbs, is involved. The wheals are remarkable 
for their capricious nature. They appear and disappear 
many times in the course of the attack, but do not, in pref- 
erence, return upon the old site. About the head they have 
a tendency to show themselves upon the forehead, ears, and 
nose, producing considerable swelling and great disfigure- 
ment. They usually occur isolated here, and do not incline 
to run together to the same extent as upon the trunk; in 
the latter region large, solid patches of wheals, the size of 
the palm or larger, are not uncommon. The burning and 
stinging sensations are now intense and almost intolerable. 
In a variable time, from an hour to a day, the symptoms 
begin to subside; new wheals cease to appear, and the efflo- 
rescence by degrees fades away until no traces of it remain. 
The termination of the attack is greatly influenced by the 
removal of the exciting cause, as well as by active treatment. 
Relapses may take place, but they are exceptional. 

Chronic Urticaria. — Here the condition, viewed as a 
whole, is of a chronic nature, and continues for months or 



[50 EXUDATIONS. 

years, or, indeed, as long as the cause exists. The individual 
wheals incline to come and go in the same evanescent man- 
ner as in the acute form, but the patient is rarely entirely 
free from them. No sooner has one crop disappeared than 
another starts up, the skin being in an almost constant state 
n{' efflorescence. At times the wheals are persistent, and 
last for hours or longer. The symptoms of general disturb- 
ance, so prominent in acute urticaria, are usually wanting, 
the individual very often seeming to enjoy average health, 
with the exception of his trouble. In other cases, the cause 
which gives rise to the skin affection may be of such a nature 
as to occasion general ill health. 

Etiology. — The causes of urticaria are numerous, and are 
often of a very diverse nature. Certain external irritants or 
poisons to the skin are capable of producing it in a marked 
degree ; the stinging nettle, jelly-fish, caterpillars, fleas, bed- 
bugs, and mosquitoes, are not infrequent causes. The more 
sensitive the skin the greater will be the disturbance when 
such agents are brought into contact with it. 

Among the internal causes, gastric and intestinal derange- 
ments are by far the most common ; they may be looked 
upon as productive of the vast majority of acute urticarias. 
An overloaded stomach, excess in wine, or highlj'-seasoned 
food, may occasion an attack. Certain articles of food, as 
fish, oysters, clams, crabs, lobsters, pork, especially sau- 
sage, oatmeal, mushrooms, raspberries, and strawberries, are 
known to play a conspicuous role in calling forth the affec- 
tion. A number of medicinal substances, taken internally, 
may likewise occasion the disease ; of these copaiba, cubebs, 
turpentine, and valerian may be mentioned. Copaiba is a 
not infrequent cause, and is usually observed to bring on the 
rash in great profusion. It will be understood that in cases 
in which the eruption is produced by the ingestion of any of 
the above enumerated articles, a more or less pronounced 
idiosyncrasy exists. 

Any irritation in the bowel may give rise to urticaria; 
intestinal worms, for example, especially in children, may 
prove a source of the complaint. Sudden emotion or unusual 
excitement, in certain individuals, may be quite sufficient to 



URTICARIA. 151 

bring it out. In females, menstrual and uterine difficulties 
are very often accompanied by urticaria; pregnancy, like- 
wise, is at times attended by it. Organic disease of the 
uterus may give rise to the affection. 

Urticaria is most intimately associated with the nervous 
system. It is often noted in connection with various nervous 
disorders, as spinal irritation, neuralgia, and asthma. There 
is also at times a close relationship between it and certain 
general diseases, as purpura and rheumatism. 

The causes of chronic urticaria are usually obscure ; not 
infrequently they may be found in spinal trouble, or organic 
disease of certain organs, as, for example, the uterus or kid- 
ney. Sometimes the causes are so slight as to be scarcely 
reconcilable with the amount of local disorder. 

Mode of life, habit, exercise, change of air, are all known 
to exert an influence over the affection. 

Pathology. — Upon close examination, a wheal is seen to be 
a more or less firm or hard elevation, consisting of a circum- 
scribed collection of semi-fluid material which has been ex- 
uded into the upper layers of the skin. The process is an 
acute, inflammatory one, and has its seat, for the most part, 
in the papillary layer. Neumann* excised and examined 
with the microscope wheals which had been excited by the 
sting of the nettle upon rabbits. The condition found was 
that of marked oedema of the tissues with a diminution in 
the supply of blood. 

The circulation in a wheal is always seriously interfered 
with, and at times altogether obstructed. The blood is 
forcibly driven from the centre to the periphery, producing 
the characteristic whitish apex and red areola. What part 
the nerves, and what part the muscular fibres of the skin, 
take in the production of wheals is still the subject of in- 
vestigation. There can be no doubt, however, that the 
nerves play a very important part in their formation. 

The wheals of urticaria papulosa are peculiar, consisting 
primarily of a wheal, which induces subsequently a deposit 
of plastic material. 

* Hand-Book of Skin Diseases, p. 135. Amer. ed., New York, 1872. 



152 EXUDATIONS. 

Diagnosis. — When the nature of the anatomical lesion, a 
wheal, is called to mind, no difficulty should arise in dis- 
tinguishing urticaria from other affections. The peculiar 
sensations of pricking, burning, and stinging, together with 
the remarkably sudden appearance of the efflorescence, are 
characteristic. Its presence as a complication with other 
diseases may sometimes lead to confusion in the diagnosis; 
but in these cases it is to be remembered that it is only a 
secondary production, and consequently of minor impor- 
tance. 

Erythema papulatum and tuberculatum are allied to urti- 
caria in their nature, as well as at times in their appearance ; 
they may, however, always be diagnosed by the absence of 
itching. In erythema there are, moreover, no wheals, but 
papules, which possess a very different history. 

Erythema nodosum bears some resemblance in appearance 
to urticaria; but the tumors are very much more elevated, 
are hard and persistent, and are unattended with itching. 
Urticaria should not be mistaken for erysipelas, an error 
which might occur when it is extensively developed over the 
looser tissues of the face. 

Treatment. — The first point in the management of a case 
of urticaria is the thorough. investigation of the cause which 
has given rise to the attack. In the greater number of cases 
this may be readily detected, and will be found to consist in 
some of the disorders referred to in speaking of the etiology. 
To remove or to relieve these, is the work to be at once taken 
in hand. 

When acute and due to gastric disturbance, the treatment 
is to be regulated somewhat by peculiarities of the individ- 
ual, and also by the severity of the attack. The precise 
articles of food which the patient has been partaking of 
should be rigidly inquired into; their quality, as to fresh- 
ness, etc., should also be made a matter of scrutiny. The 
possibility of the patient having eaten anything unusual 
should also be considered. In severe cases an emetic of sul- 
phate of zinc, ipecacuanha or mustard may be administered, 
especially if food is supposed to be still in the stomach. The 
bowels should be evacuated at once, and for this purpose 



URTICARIA. 153 

the saline purgatives, such as sulphate of magnesium and 
Rochelle salt, will be found most useful. Free movement 
from the bowels should in every case be obtained as soon 
as possible; the repeated use of mild aperients, moreover, 
should be continued until entire recovery has taken place. 
The diet should be of the most simple kind, with the avoid- 
ance of all stimulating food and drink. 

Other cases, not caused by any discernible intestinal de- 
rangement, may often in like manner at first be treated 
advantageously by saline draughts, after which the mineral 
acids or other remedies, and a strict dietary regimen, may be 
prescribed. But the treatment for a given case cannot be 
determined until its nature and cause have been fully inves- 
tigated ; those remedies which appear then as being most 
suitable to the case should be prescribed and persisted in. 
Where there is a disposition to acidity of the stomach, a 
condition of frequent occurrence, alkaline preparations are 
valuable. Bicarbonate of sodium in live or ten grain doses, 
lime water, liquor potassse in small doses, and other similar 
remedies may be employed with good result. Subnitrate of 
bismuth, combined with small doses of calomel and opium, 
is likewise useful in allaying the irritability of stomach which 
is so apt to follow acute urticaria. The alkaline mineral 
waters are often refreshing and agreeable to the patient. 

In chronic urticaria the bowels should be carefully regu- 
lated by means of laxatives. The food should be nourishing 
but plain. Attention should in every case be directed to the 
state of the general health. Inasmuch as the causes of chronic 
urticaria are apt to be exceedingly diverse in their nature, 
and to be in many instances obscure, each case will require 
special study. Very frequently the cause will be found to 
be apparently insignificant, and altogether out of proportion 
to the amount of cutaneous disturbance. Whatever the de- 
rangement, no matter how slight it may appear, it should at 
once be remedied, if possible. 

In many cases diuretics are indicated; the acetate of potas- 
sium in twenty or thirty grain doses, well diluted, is a ser- 
viceable remedy. The natural alkaline spring waters, as, 



1 5 1 EXUDATIONS. 

for example, those of Vichy, France, and Saratoga (Saratoga 
Vichy Spouting Spring), may at times be directed with the 
best results. If gouty symptoms are present, they must be 
encountered by the use of alkalies, colchicum, or other 
mesne adapted to the requirements of the case. Quinine 
often proves a valuable remedy, not only in cases bearing 
an intermittent type, but also in other instances. Arsenic 
is of service at times when other remedies fail ; it is well 
spoken of by Wilson, Milton, Hardy, and others. Iron 
may also not infrequently be prescribed with advantage. 
Bromide of potassium, chloral, and other sedatives will be 
found useful to calm the nervous system, which is often very 
much disturbed by long suffering. In some cases, where 
the disease is persistent and due to no appreciable cause, 
the bromide of potassium in full doses may be given with 
the hope of permanent relief: McCall Auderson mentions it 
favorably in this connection. Change of climate occasionally 
proves of benefit when all other means have failed. 

Local treatment is of great importance. The burning and 
stinging sensations peculiar to this affection are often so dis- 
tressing as to call for the most prompt and energetic external 
remedies. The patient should be divested of all woolen or 
other irritating underclothing. The bed coverings at night 
should be light, and the sleeping apartment kept cool. 

Baths and lotions constitute the most desirable method of 
applying remedies ; they may be prepared with various sub- 
stances, and may be used either warm or cold, as may seem 
to afford the most relief. As the disease is very apt to be 
obstinate and rebellious to treatment, I shall refer to a 
number of remedies which may be employed to allay the 
disagreeable sensations, for experience teaches that where 
one fails another may prove serviceable. 

Sponging the parts with vinegar and water at times affords 
ease. Salt water baths may also be used with good result in 
some cases. One of the best remedies, in my experience, is 
alcohol, in one form or another, as, for example, brandy or 
whisky. It may be applied as a lotion, either diluted or in 
full strength, and will in the majority of cases be found to 






1 



URTICARIA. 155 



give decided relief. It should be employed frequently, or as 
often as may be necessary, in the course of the twenty-four 
hours. 

Alkaline baths, made with the carbonates of sodium and 
potassium, afford much relief. They may be prepared of 
varying strength, according to the susceptibility of the skin 
and the amount of water. For an ordinary tub, containing 
about thirty gallons of water, three ounces each of the car- 
bonate of sodium and bicarbonate of potassium constitute 
the average strength; more or less may be added to suit 
the case. A handful of starch, boiled in a quart of water, 
may be added to the bath with advantage. Starch, gelatine 
or bran baths, prepared in the manner just indicated, are 
also serviceable. Sulphuret of potassium, from one to two 
ounces to the bath, is another remedy which may often be 
employed with good result: Fox speaks well of it. Acid 
baths, as, for example, those containing hydrochloric and 
nitric acid, are also recommended. Hardy, at the Hopital 
St. Louis, Paris, frequently obtains benefit from the nitric 
acid bath, — a half ounce to thirty gallons of water. In all 
baths where the patient is expected to remain in the water 
for a half hour or longer, the temperature of the water should 
be from 90° to 95° F., — comfortably warm. 

Carbolic acid with water, from one to two drachms to the 
pint, is a lotion which I have employed with excellent result. 
Lotions containing the corrosive chloride of mercury enjoy 
notable repute; about five grains to the pint of water, or 
better, dilute alcohol, may be prescribed. Dilute hydrocy- 
anic acid also enjoys considerable distinction; from one to 
five drachms to the pint of water may be used. Chloroform, 
in the form of an ointment or lotion, is another well kuown 
and valuable remedy, ^eligan was one of the first to em- 
ploy it, in the strength of a half drachm to the ounce of cold 
cream; Gull, Anderson, and others, have since called atten- 
tion to its value as a remedy in obstinate cases of the disease. 

Prognosis. — A few days usually suffice for the relief of 
acute urticaria, when due to gastric derangement. Relapses 
in these instances are exceedingly liable to occur whenever 
the patient is exposed to the exciting cause. 



156 EXUDATIONS. 

The chronic variety is of a much more serious nature, 
and is generally very stubborn in its course. The prog- 
nosis must vary with the likelihood of the removal of the 
cause. 

ECZEMA. 

Syn. Tetter; Germ., Eczem ; Fr., Eczema. 

Eczema is an inflammatory, acute or chronic, non-conta- 
gious disease of the skin, characterized at its commence- 
ment BY THE APPEARANCE EITHER OF ERYTHEMA, PAPULES, 
VESICLES OR PUSTULES, OR A COMBINATION OF THESE LESIONS, 
ACCOMPANIED BY INFILTRATION AND ITCHING, TERMINATING EITHER 
IN DISCHARGE WITH THE FORMATION OF CRUSTS OR IN THE PRO- 
DUCTION OF SCALES. 

Symptoms. — It will be noted that the term eczema is em- 
ployed in a broad sense, and is made to include a number of 
diverse lesions. Several ofthe.se forms of disease have until 
quite recently been viewed as distinct affections. With the 
light of modern pathology, however, we are now enabled to 
group them together as belonging to one process. As we 
shall presently see, they are but varieties and stages of one 
disease. 

Regarding, then, these varied manifestations in this man- 
ner, their study becomes immensely simplified. Indeed, it 
is only by so interpreting the subject, it seems to me, that 
eczema can be at all comprehended. 

The affection exhibits itself in various lesions. It is emi- 
nently a protean disease. At one time it starts as an 
erythema; later, perhaps, this erythema becomes a moist, 
excoriated patch, and terminates finally in a thickened, dry, 
desquamative surface. At another time it commences in 
the form of vesicles or pustules, seated upon highly inflamed 
bases, with swelling and heat; the vesicles soon burst, and 
there results a red, weeping surface, pouring forth a liquid, 
gummy discharge, which quickly dries into bulky crusts. 
The character of this patch may now suddenly change, and 
instead of a weeping, excoriated surface there exists a dry, 
scaly, infiltrated, fissured piece of skin, which continues until 
the disease is removed. Or, again, papules may first appear; 



ECZEMA. 157 

these may remain as such throughout their course or may 
pass into other lesions, or they may be associated with 
vesicles. 

Such is a brief outline of the changes which may, and 
commonly do, take place in eczema. There is no other af- 
fection of the skin in which the lesions, both primary and 
secondary, undergo so many and so sudden alterations; not 
infrequently we may observe every variety of eczema mani- 
festing itself in turn upon the same individual. This subject 
will be referred to more at length in the consideration of the 
several varieties of the disease. 

More or less infiltration of the tissues is present in every 
case of eczema. 

The exudation, whether fluid or plastic, is always consid- 
erable, and in the majority of instances is excessive, giving 
rise either to discharge and crusts or to the deposition of 
plastic material. 

The presence or absence of discharge, that feature which 
for so long a time was regarded as a sine qua non of eczema, 
will depend entirely upon the lesions in which the process 
manifests itself. In the vesicular and pustular forms the 
amount of fluid exudation is usually very great, and is fol- 
lowed by extensive thickening as well as crust formation. 
On the other hand, in the erythematous and papular varie- 
ties no discharge takes place, and consequently no crusts 
appear; more or less desquamation, however, is present in 
these cases, varying in amount with the stage of the disease 
and the locality attacked. 

Itching is a constant symptom of the affection ; it is always 
present. It varies in intensity from that which is annoy- 
ing to that which is almost unendurable. At times the sen- 
sation is that of burning rather than itching; in other cases 
they occur together. 

Eczema runs its course either as an acute affection lasting 
a few days or weeks, and then disappearing not to return, 
or, as is much more usually the case, it assumes a chronic 
state, continuing with more or less variation for months or 
years. As a rule, when left to itself eczema inclines to settle 
in the skin and to remain there for an indefinite period. The 



158 EXUDATIONS. 

acute cases — those disposing to terminate in spontaneous 
recovery — are the exceptions. 

Eczema may appear as a limited eruption, in the form of 
variously sized and shaped single or multiple patches, its 
usual mode of distribution, or it may show itself as a dif- 
fused disease, involving the greater part or the whole of the 
body. 

Unless occupying an extended area of surface, it is seldom 
ushered in with any symptoms of constitutional disturbance. 

The varieties of eczema are named according to the lesions 
which the disease assumes at its commencement. 

I shall treat of these separately and in detail. 

Eczema Erythematosum. — The primary lesion here is a 
macule, — an erythema. The course of a typical case may 
be described as follows. The condition first noticed is an 
erythematous state of the skin, undefined as to outline, and 
very commonly fading imperceptibly into the surrounding 
healthy skin. The affected surface may be small or large ; 
it may be the size of a coin, as, for example, upon the nose, 
or it may be as large as the hand or larger. There is always 
more or less swelling present, varying with the locality and 
the amount of surface invaded. There is no discharge or 
moisture. Ordinarily, the patch is covered with a thin film 
of dry epidermis or scale; at times the mucous layer is 
exposed. 

The color of the skin is usually bright red; it is also 
often yellowish-red, and may have a lurid look. It may be 
uniformly diffused over the affected part, or, as frequently 
occurs, it may be mottled or in the form of patches or 
blotches. Upon the face, in particular, great variation in 
color is apt to manifest itself; at one time it is brilliant, at 
another time dull. 

The disease may either remain localized to a small area 
or it may invade a large surface. The process varies greatly 
in intensity from time to time; it is apt to be better one day 
and worse the next; it may even disappear wholly for a time 
and then suddenly show itself again. Its course is variable. 
It may pass off completely at the end of a week or two, or 



ECZEMA. 159 

it may assume a chronic course, attended by considerable 
thickening of the tissues. It is exceedingly liable to relapse. 
The influence of external heat or of excitement always ag- 
gravates the condition, causing exudation, itching, and other 
symptoms. A heavy meal, or indulgence in alcoholic drink, 
is very apt to be followed by an exacerbation. The burning 
and itching sensations are in almost all cases very violent ; 
they always constitute prominent symptoms. 

Eczema erythematosa! m may remain as such until it finally 
disappears, or it may undergo various changes, as, for ex- 
ample, into a moist, weeping eczema, with more or less 
crusting. The locality attacked often determines the form 
into which it is likely to pass; occurring where two surfaces 
naturally come into contact, as, for example, about the 
genitalia, eczema intertrigo commonly results. In the ma- 
jority of instances, however, it terminates in desquamation, 
becoming eczema squamosum. 

Vesicles or pustules are very rarely seen in the course 
of this variety of the disease, the patch or patches usually 
remaining in the erythematous or squamous state throughout 
their entire duration. 

Eczema erythematosum ordinarily shows itself about the 
region of the face, particularly upon the forehead and nose; 
it also occurs upon the genitalia, and on other parts of the 
body. 

Eczema Vesiculosum. — This is the commonest variety of 
the disease. It is to be regarded as the type of eczema. The 
affection usually appears in the following manner. There is 
a feeling of heat and irritation about the part for a short 
time preceding any sign of eruption; then, a diffused or 
punctate bright redness manifests itself, accompanied by 
great itching and burning, which continues to increase until 
in a very short time numerous, minute, pin-point to pin-head 
sized vesicles appear. They are either isolated or closely 
packed together; frequently they run into one another, 
making a solid patch. The vesicles grow more prominent 
hour by hour, until soon they become tensely distended with 
a clear fluid. The tissues are swollen, hot, bright red in 
color, and the itching so intense that the patient is unable 



1G0 EXUDATIONS. 

to resist the impulse to scratch. The process is now at its 
height, and thus far has run an exceedingly rapid course. 
But the disease does not remain long in this condition ; the 
vesicles soon rupture, either of their own accord or through 
scratching, the liquid spreading itself over the surface and 
at once drying into yellowish crusts. New crops of vesicles 
subsequently come out, or, on the other hand, the liquid 
exudes so rapidly from the skin that there is actually no 
time for vesiculation. Through maceration of the epidermis, 
and rubbing and scratching of the part, there soon results an 
excoriated, more or less red, weeping surface. The amount 
of crusting will depend upon circumstances, as, for example, 
the locality involved, exposure to the air, the removal or not 
of old crusts, etc. The disease may continue in this state 
for a few days, when the various symptoms will gradually 
subside, or, on the other hand, they may all become aggra- 
vated, the disease in this event passing into another and 
more lasting stage, which has received the name of eczema 
rubrum. 

The typical vesicular eczema just described is met with 
frequently enough in one stage or another of its course; 
more often, however, associated with the vesicles we find 
also papules, papulo-vesicles, pustules, and other lesions. It 
is in these latter cases, and they are very common, that the 
variable character of eczema is most manifest. The lesions 
are often so multiform, indeed, that it becomes a matter of 
difficulty to determine whether, for example, vesicles or 
pustules predominate. 

The vesicles of eczema remain as such for but a short time, 
for as soon as fully developed, or even before this stage, they 
burst spontaneously. Their contents, consisting of clear, 
serous, yellowish, gummy liquid, pour over the surface, and 
desiccate rapidly into light-yellow, honeycomb-like crusts 
(melitagra). The quantity of fluid exuded is often very 
great. 

Itching is the most prominent subjective symptom; it is 
always intense, and gives rise to an irresistible desire to 
scratch. After the vesicles have been opened, and the fluid 
allowed to escape, the itching subsides somewhat; burning 



ECZEMA. 161 

sensations are now usually complained of. With the advent 
of another crop of vesicles the itching returns. 

Vesicular eczema may involve a small surface only, or 
it may occur extensively over various regions of the body. 
It frequently shows itself upon the face, in both children 
and adults; in the former it constitutes the crusta lactea of 
older writers. It also shows itself very often about the hands 
and lingers. 

The vesicles show no tendency to group, and occur with- 
out regularity of distribution. They form about the open- 
ings of the hair follicles and on other parts of the skin 
without preference. 

Eczema Pustulosum. — This variety, called also eczema 
impetiginosum, is closely allied to the preceding, the only 
difference being that the lesions assume the form of pustules 
rather than of vesicles. The pustules are formed in the 
same manner as the vesicles, which have been described, 
except that there is not the same amount of swelling, heat, 
and itching present. The pustules are apt to be somewhat 
larger than the vesicles, and are, as a rule, firmer in consist- 
ence. They develop as pustules, or, as is often observed, 
they become pustules from vesicles; again, both lesions may 
exist at the same time, side by side, upon one individual. A 
strict line cannot be drawn between vesicles and pustules. 

As in the case of the vesicles, the pustules burst and 
are replaced by thick, bulky, greenish-yellow or brownish 
crusts, which are apt to cover the skin completely. If the 
process continue, they accumulate in quantity, causing great 
disfigurement. They desiccate quickly and become friable, 
and finally fall off or crumble away. 

Eczema pustulosum shows itself most frequently upon the 
scalp and face; it is common in these regions in children 
and young people, more especially in those who are ill fed 
and improperly cared for. Upon the scalp it usually assumes 
a serious and stubborn character. The pustules are apt to 
appear here in great numbers, often involving the whole 
surface of the scalp, and giving rise to a most distressing 
form of the disease. The eruption may be so excessive as 
to invade every portion of the scalp, undermining, as it were, 

11 



162 EXUDATIONS. 

the whole epidermis by the coalition of the pustules. Pus- 
tular eczema occurs for the most part in those whose systems 
are below standard, and in those who manifest signs of the 
scrofulous habit. 

Eczema Papulosum. — This variety, known formerly as 
lichen simplex, is characterized by the appearance of pap- 
ules rather than of vesicles or other lesions. Although long 
considered as a disease distinct from eczema, and termed 
lichen, it is now recognized as one of the varieties of eczema. 
Its eczematous nature was first pointed out by Hebra. 

It appears in the form of small, round or acuminated 
papules, varying in size from a pin-head to a small pea. In 
color they are reddish ; at times they are bright red, in other 
cases darker. They may be either discrete or confluent, 
and may occur either in patches or in a disseminated man- 
ner over a considerable surface, without regularity of dis- 
tribution. Ordinarily they begin as papules, and continue 
throughout their entire course as such. At times, however, 
they commence as papules and pass on into other lesions, 
as vesicles; or, they may be associated with vesicles, both 
lesions occurring at the same time. Thus, in papular ec- 
zema, while true papules predominate, imperfectly-formed 
papules, half-developed vesicles, or even typical vesicles may 
appear. It is this clinical fact which proves the identity of 
•the process, and that the vesicular and papular varieties 
are but manifestations of one and the same disease. 

Where the papules are overcrowded they are apt to run 
together and form solid patches, which, if they be subjected to 
violent scratching or other irritation, may become abraded 
and result in eczema rubrum. Inasmuch, however, as the 
papules are usually discrete, this seldom occurs. 

The papules are exceedingly persistent; they may continue 
for some time without undergoing marked change, or they 
may disappear and be replaced by others. Where they 
aggregate in the form of patches, infiltration is usually 
extensive. Papular eczema attacks by preference the arms, 
trunk, and thighs. It may invade a portion or the whole of 
the body. It is the most obstinate variety of eczema, and is 
at times exceedingly rebellious to treatment. 



ECZEMA. 103 

The subjective symptoms are more violent than in any 
other variety of the disease. The itching is intolerable, and 
always constitutes a prominent symptom. Patients scratch 
themselves severely, tearing the tops of the papules and 
causing them to bleed. Small blood crusts may almost 
always be noticed here and there over regions which are 
accessible to the hands. 

Having described the varieties of eczema considered from 
the stand-point of the primary lesions, there remain still cer- 
tain forms of the disease which, although not, strictly speak- 
ing, varieties, are important, and call for special description. 
The first to which attention will be directed has alread}- 
been incidentally referred to under the heads of eczema erv- 
thematosum and vesiculosum, namely, eczema madidans, or 
eczema rubkum. This must be regarded rather as a con- 
dition, resulting from previous morbid action, than as a 
variety of the disease. It is to be viewed as a variety only 
in a clinical sense. 

Eczema madidans, or eczema rubrum, may result either 
from eczema erythematosum, vesiculosum, pustulosum, or 
papulosum, as already indicated. It is characterized by a more 
or less reddish, weeping surface, accompanied by marked in- 
flammatory symptoms. Serum exudes freely, and at once 
forms into crusts; blood likewise oozes forth from the lacer- 
ated and exposed corium, which, together with the serum, 
dries into thick, bulky, dark-yellow crusts, completely en- 
veloping the region. These crusts adhere closely and firmly 
to the part, and, unless detached by mechanical means, may 
remain there indelinitely, the disease continuing its course 
beneath this mass of effete matter. Eczema madidans, then, 
presents two appearances, — as it occurs with its crust, and as 
it exists without this covering. In the one case the skin 
itself is altogether obscured by a dirty yellowish or brownish 
crust ; in the other the skin presents a bright red, punctate, 
wounded surface, deprived in great part of its epidermis, and 
exuding a clear, syrupy, yellowish fluid. 

Eczema madidans may occur upon any part of the body. 
It is most commonly seen upon the legs, particularly in 



164 EXUDATIONS. 

elderly people, in the form of extensive patches, often occu- 
pying the whole surface of the limb. It is for the most part 
chronic in its nature, not only the skin but the deeper tissues 
also becoming more or less involved. Infiltration takes place 
in a marked degree; the skin becomes greatly thickened 
and hardened, feeling at times, in old cases, almost leathery. 
Eczemas in this condition may continue for years, showing 
not merely no disposition to spontaneous recovery, but, on 
the contrary, tending steadily to increase in their develop- 
ment. The flexures of the joints likewise are often the seat 
of eczema madidans ; the groins, and the cleft between the 
nates, are also frequently affected, the condition in these in- 
stances usually arising out of an eczema erythematosum. 

Another important clinical variety or form of eczema is 
that termed eczema squamosum. It is to be viewed as a 
stage of one or another of the four varieties of eczema; it 
may follow the erythematous, vesicular, pustular, or papular 
manifestations of the disease. As already pointed out, it is 
very apt to succeed eczema erythematosum. In other cases 
it shows itself at the termination of the vesicular and pus- 
tular varieties, in the form of dry, harsh, scaly patches. 
Papular eczema, when the lesions are confluent, or are seated 
so close together as to constitute a solid patch, may also 
result in squamous eczema; patches of this kind are often 
met with upon the extremities. 

Eczema squamosum, when typical, is characterized by 
variously sized and shaped, reddish patches. They are dry, 
and are more or less scaly. At times the scales constitute a 
prominent feature, in other instances they are scanty; the 
locality attacked determines to some extent the amount of 
desquamation. Infiltration is always present in squamous 
eczema. In the majority of cases, where the patches have 
existed for some time, it is pronounced. When the skin is 
taken up between the fingers, it is felt to be thickened; this 
feature, of course, exists in all degrees. It may be slight, or, 
on the other hand, very extensive, the amount of thickening 
depending upon peculiarities of the case. 

Squamous eczema may be, and is in very many cases, 
merely an ephemeral stage of the disease, showing itself for 



ECZEMA. 165 

a short time only previous to the disappearance of the affec- 
tion. The term is commonly employed, however, to denote 
the chronic squamous stage of eczema, which may continue 
without notable change for an indefinite period. 

Other lesions are encountered in eczema, as they occur 
upon one part of the body or another, which, having pecu- 
liarities of a denned character, are worthy of mention. 

Rhagades, or fissures, are observed not infrequently upon 
those regions which, by their natural conformation, are sub- 
ject to constant motion ; the various joints, particularly the 
hands and fingers, are usually the seat of fissures of more or 
less severity ; at times they are very extensive, deep, bright 
red in color, showing the true skin, and so painful that motion 
is almost impossible. They usually occur about the normal 
furrows of the skin, but they may show themselves anywhere. 
They are produced for the most part by motion or strain 
upon the eczematously diseased tissues, which in many indi- 
viduals incline readily to split and form fissures. They are 
found, more or less developed, in all the varieties of eczema. 
The condition is termed eczema fissum or rimosum ; the 
French make it a variety of the disease, and call it eczema 

FENDILLE". 

The so-called chaps, as they take place about the hands, 
face, or other localities, are lesions which are liable to occur 
in skins which have a disposition to eczema, or in those 
which are abnormally tender. They may also be brought 
about by the use of external irritants, as strong soap, the 
excessive use of water, acids, and similar substances. Ex- 
posure to cold weather and hard manual labor are the usual 
sources of this lesion. 

In thickened, infiltrated, localized patches of eczema a 
peculiar wart} 7 , verrucous condition at times shows itself, 
the appearance being due to a hypertrophied state of the 
papillse. The condition may be very properly called eczema 
verrucosum, as suggested by Wilson ; if simply hard, rather 
than wart-like, eczema sclerosum. 

Acute and Chronic Eczema. — A very natural, and at the 
same time important and proper, division of eczema is that 



166 EXUDATIONS. 

into acute and chronic. The line which separates the two 
conditions is one which may usually be drawn by means 
both of its clinical and of its pathological features. The di- 
vision relates not so much to time, as it does to certain patho- 
logical changes which occur during the course of the disease, 
and which it is necessary to bear in mind in viewing the 
subject of treatment. Eczema, as a rule, inclines to run a 
chronic course; there are, however, many exceptions, con- 
stituting examples of typical acute eczema, where the whole 
process completes itself in a brief period. So long as the 
general inflammatory symptoms are high, and the secondary 
changes insignificant, the disease may be said to be acute ; 
when, however, the process has settled itself into a definite 
line of action, continually repeating itself, accompanied by 
secondary changes, the disease is to be considered as chronic. 
The terms are also at times applied to the length of time 
which the disease has existed. 

Etiology. — Eczema is by far the commonest of all the dis- 
eases of the skin. It occurs more frequently in some coun- 
tries than in others. In Philadelphia, according to my 
experience, it constitutes almost fifty per cent, of the entire 
number of cutaneous diseases. In Boston, according to 
White,* the percentage is almost as great; out of 5000 
cases of skin disease encountered in the out-patient depart- 
ment of the Massachusetts General Hospital, 2242 were 
eczema. In New York, Bulkleyf makes the proportion 
less, — namely, about one-third of all the cases. Anderson,! 
in Glasgow, out of 10,000 cases in hospital practice encoun- 
tered 2527 examples; while Hebra,§ in Vienna, out of 29,535 
cases met with in thirteen years in the General Hospital, 
records only 2195 cases. Thus it will be noted that the 
disease is much more frequent in this country than abroad. 

It attacks people in all spheres, the rich as well as the 
poor, and may appear at any period of life from infancy to 
old age. 

* Boston Medical and Surgical Journal, Jan. 27, 1876. 

f American Practitioner, May, 1875. 

X The Lancet, Nov. 11, 1871. 

I Neumann's Lehrbuch der Hautkrankheiten. Wien, 1873. 



ECZEMA. 167 

Males and females are affected in about like proportion, 
although very extended statistics prove it to be somewhat 
more frequent in males. 

In certain cases it is hereditary, the term being used in 
the sense that a predisposition to its development is handed 
down from parent to child. On the other hand, in the vast 
majority of cases no hereditary taint is to be detected. 

All temperaments are by no means equally liable to the 
disease; individuals with light hair and florid complexion 
suffer more frequently than those with dark hair and skins. 

There are, moreover, certain persons so peculiarly consti- 
tuted that their skins are ever ready to manifest signs of 
eczema upon the slightest provocation, whether this be in 
the form of internal or of external irritants. For example, 
it is well known that in certain people local irritants inva- 
riably tend to bring out eczema, while the same kind and 
amount of irritation upon others produce at most a simple 
dermatitis, which passes away completely with the removal 
of the cause. In like manner, in these cases, internal de- 
rangements of various kinds are often sufficient to cause 
eczema to appear, while, as we are well aware, no amount of 
like irritation in another class of persons will occasion the 
least symptom of eczema. I would state, then, that there 
seems to be a certain inherent peculiarity of constitution in 
some, which, under favorable circumstances, encourages the 
appearance of eczema. 

Constitutional Causes. — Here are to be found many 
conditions which are capable of giving rise to the disease. 
They play a most important part in the production of 
eczema, and, having called it forth, exert a powerful influ- 
ence in keeping up the process. 

Chief among the constitutional causes I would rank the 
various disorders of the digestive tract. Dyspepsia (the term 
being employed in its broadest sense), with its vast train of 
symptoms, is to be regarded as one of the commonest causes. 
Constipation, irregularity in the action of the bowels, flatu- 
lence, dyspepsia of the stomach and intestine, and other 
similar states, may frequently be observed to be the source 
of the eruption. 



168 EXUDATIONS. 

Deficient excretion through the various emunctories of the 
body is to he regarded as a cause. In certain individuals 
the presence of an excess of uric acid and urates in the 
system is quite sufficient to produce and to keep up eczema. 
The association of gout and rheumatism with eczema has 
long been recognized by observers; without question, the 
presence of the gouty or rheumatic vice, in some subjects, 
strongly disposes to attacks of eczema. 

As causes of eczema, certain writers have insisted upon 
the following somewhat unsatisfactory explanations, which 
I shall very briefly mention. Mr. Wilson, for example, con- 
siders that it is due to "constitutional or general debility," 
which may present itself as "assimilative debility," as "nu- 
tritive debility," or as " nervous debility." Other observers 
consider that "perverted innervation" is to be viewed as the 
chief cause; others, again, that it is due to the "strumous 
or scrofulous state." It is manifest, however, that these 
expressions are too vague in their meaning to be of any 
practical value. 

Improper food, either as to quantity or quality, also acts 
as a cause. This remark is applicable in the case of both 
adults and infants, but is especially true concerning the latter, 
where the continued use of unsuitable diet frequently leads 
to serious disturbance of the health and eczema. 

In certain cases, pregnancy and the period of lactation 
possess a decided influence in calling forth the disease. In 
the same way, all causes which tend to lower the average- 
degree of health may serve as generators of eczema. It is 
in this sense that debility, nervous exhaustion, excessive 
mental or bodily work, and kindred states, act with mani- 
fest force in producing and in maintaining the disease. 
Eczema is very often dependent upon a chlorotic state, the 
disease clinging tenaciously to the patient until the general 
condition has become improved. Various kinds of internal 
irritation, such as ascarides or taeniae in the bowel, may de- 
termine an eczematous eruption. 

Dentition may operate as a cause, and may occasion the 
disease to appear in infants who are predisposed to it; but 
it is to be viewed in the light of a cause only as in the case 



ECZEMA. 169 

of any other source of irritation to the constitution. The 
process, as we know, is one which not infrequently creates 
considerable systemic disturbance. 

Vaccination, at times, occasions an outbreak of eczema, 
but this occurs only in those who have already a tendency 
to the affection, the general disturbance to the system re- 
sulting from this operation being quite sufficient to call it 
forth. 

Eczema is not contagious. It cannot be acquired from 
being in contact with or from handling the patient; nor can 
it be taken from the discharge. 

Local Causes. — These are numerous, and are worthy of 
careful investigation; they play a conspicuous part in the 
production of many eczemas. They give rise to the so- 
called artificial eczemas. They are all cutaneous irritants, 
which act injuriously upon the skin. Mineral and chemical 
substances of various kinds are not infrequently the source 
of trouble. The improper external use of the preparations 
of mercury, for example, is capable of giving rise to eczema, 
as is seen in the condition termed eczema mercuriale, which 
results from the excessive employment of mercurial frictions. 
The form of eruption here does not differ materially from 
that provoked by other similar substances. Croton oil, one 
of the most powerful of irritants, tincture of arnica, tinc- 
ture of cantharides, mustard, antimonial ointment, sulphur, 
turpentine, and other like substances, all have a part in the 
production of the artificial eczemas. Dye-stuffs, especially 
those containing aniline, are highly injurious to the skin ; 
undergarments, shirts and socks, dyed with this alkaloid, 
are known to occasion vesicular eczema. 

The effects resulting from contact with the poison vine 
(Rhus toxicodendron) and poison tree (Rhus venenata) are 
well known, and exhibit forcibly the virulent influence 
which certain vegetable substances are capable of producing 
when brought into contact with sensitive skins. The condi- 
tion produced by these poisons is an artificial eczema, which 
may be of an erythematous, a vesicular, or a bullous char- 
acter; the eruption, pathologically, possesses all the features 
of an eczema. It is well recognized that certain persons 



170 EXUDATIONS. 

are always attacked when they come in contact with either 
of these plants, while others are able to tonch and handle 
them with impunity, the skin in these latter cases being 
altogether insensible to their deleterious influence. This 
observation demonstrates very clearly the great difference 
which naturally exists in the degree of sensitiveness of 
skins, and aids in explaining the whole subject of artificial 
eruptions. 

Heat and cold have a share in the production of eczema ; 
the former element, especially, has long been acknowledged 
as a source of much mischief upon the skin. The heat of 
the sun, upon parts exposed for some time to its action, is 
not infrequently the cause of eczematous eruptions; the 
term eczema solare is employed to express this condition. 
Excessive perspiration, with elevation of temperature, oc- 
curring about the genitalia and other localities where the 
skin inclines to form folds, often occasions abrasion of the 
epidermis, chafing, and subsequently eczema ; when this 
occurs it is called eczema intertrigo. 

Eczema may also follow the inflammatory disorder of the 
sweat glands known as miliaria, or prickly heat, when this 
latter affection is prolonged and subjected to exasperating 
agencies, as friction, irritants, etc. 

In connection with this subject I may refer to the influ- 
ence of the seasons upon eczema. The disease is found to 
be of much more frequent occurrence in winter than in 
summer. Many examples of chronic eczema recover spon- 
taneously during the summer season, only, however, to re- 
appear with the winter. Sudden changes in the weather, 
especially from warm to cold weather, always aggravate 
these eczemas; they are not infrequently observed to be 
controlled in a remarkable manner by the seasons. 

Water may, under certain circumstances, provoke an 
eczema; it is seen at times following the inordinate use of 
baths, water dressings, fomentations, etc. 

Alkalies, and also acids, in one form or another, may be 
alluded to as causes of eczema. 

Strong soaps, particularly potash soaps, are exceedingly 
deleterious to many skins, giving rise to harshness, fissures, 



ECZEMA. 171 

and eczema. It is in place here to make mention of the 
injurious effects resulting from the improper use of sapo 
viridis, or common soft brown soap. This substance is, as 
we know, a most valuable remedy in the treatment of certain 
varieties and stages of eczema; but it is also a harsh irritant, 
capable of doing much mischief when injudiciously applied 
to the skin; artificial eczemas from its imprudent use are 
not rare. 

Two other important sources of eczema remain to be 
noticed, namely, parasites and scratching. The animal para- 
sites claim particular attention, the pediculus and the acarus 
scabiei being most prominent. Pediculi, especially those of 
the head, give rise to much disease upon the scalp, and are to 
be regarded as the cause of a not inconsiderable amount of 
eczema capitis in children. Of a like character is the inflam- 
mation of the skin produced by the ravages of the itch mite; 
the condition here differs in no way from eczema vesiculosum 
brought about by other causes. 

Lastly, scratching plays a very significant part in the pro- 
duction of artificial eczema, as seen in scabies and in phthei- 
riasis. 

Pathology. — In considering the pathology of eczema, it is 
necessary to bear in mind that we have a highly inflam- 
matory disease, which undergoes many rapid changes during 
its development. We must also remember that we have 
several varieties of the disease, as, for instance, eczema papu- 
losum aud eczema vesiculosum, each running a somewhat 
different pathological course. Finally, it is important to 
separate the acute from the chronic stage in an investigation 
into the pathology of this affection. 

Eczema possesses the following points in connection with 
its pathological anatomy. 

There is, in the first place, hyperaamia or congestion of the 
skin, as shown by the redness which is present. The blood- 
vessels and capillaries are overloaded with blood ; this may 
take place uniformly over the surface, as in the case of eczema 
erythematosum, or in points, as in eczema papulosum. The 
condition is always particularly marked about the follicles, 
as may readily be seen with the naked eye. 



172 EXUDATIONS. 

The important pathological process which occurs in the 
disease is an exudation, which may be either of a fluid or of a 
plastic quality, or of all grades between the two. According 
as the disease assumes an erythematous, papular, vesicular, 
or pustular form will the changes present one picture or 
another. 

The anatomical changes which have been observed in the 
course of the disease afford interesting knowledge upon the 
subject. Neumann's* experiment upon the skin of the ear 
of a living rabbit, consisting of the irritation of healthy 
tissue by means of croton oil, shows the changes which take 
place, in all probability, in idiopathic vesicular eczema. At 
first a rhythmical contraction of the vessels took place, they 
being at one moment distended and at the next empty, but 
becoming gradually more and more dilated, until stasis was 
observed. The skin, which, in the normal state was trans- 
parent, became opaque, swollen, and hot, accompanied, after 
a few hours, by the appearance of numerous vesicles. Forty- 
eight hours afterwards the animal was killed, and the tissue 
found to be infiltrated with serous fluid, and filled with a 
great quantity of cells. 

The changes occurring in the papular and vesicular varieties 
have been carefully investigated by Biesiadecki,f as follows. 
The principal seat of disease is the papillary layer. In cir- 
cumscribed portions of the skin the papillae are somewhat 
enlarged in breadth and in length, and are infiltrated with 
cells, and a clear, serous fluid. 

The connective-tissue corpuscles of the papillae are remark- 
able for their size and succulence, and are increased in num- 
ber. The presence of a serous fluid in the tissues of the 
papillee is made manifest by the compressed condition of 
the swollen connective-tissue fibres. The rete mucosum is 
observed to be particularly altered over the papillae affected 
in this manner. Numerous spindle-shaped cells are seen 
prolonging themselves into the mucous layer, lying half in 
the papillae and half in the deepest cells of the rete mucosum. 

* Loc. cit., p. 169. 

f Beitrage zur physiol. und pathol. Anat. der Haut. Sitzungsberichte 
der k. Akad., Wien, LVI. Bd. p. 243, 1867. 



ECZEMA. 173 

They crowd the cells of the rete apart, and reach even to 
the horny layer. These cells often form quite a dense net- 
work in the rete between the papillae, penetrating one another 
in all directions. Within this network are found somewhat 
swollen epithelial cells, whose protoplasm appears less 
marked. This circumscribed infiltration of the papillae 
forms the papule of eczema. In the further course of this 
process a vesicle may be formed. This is produced by the 
new formation of cells within the papillae, and the super- 
ficial cells of the mucous layer swelling up considerably, 
perhaps rupturing, so that the epidermis becomes raised. 
The cells in the middle of the mucous layer are more 
markedly swollen, or they may be indistinct, as if con- 
taining granular matter, the largest nuclei being scarcely 
recognizable. In cases of rapidly-developed eczema the 
connective-tissue cells are found entering the rete in greater 
numbers, and form a dense network. With the increased 
abundance of these cells there is at the same time a larger 
quantity of fluid developed in the papillae, to such an extent 
at times as to raise the epidermis up in the form of bullae. 
If the epidermis covering the vesicles be removed, the fluid 
oozes forth upon the surface of the mucous layer, consti- 
tuting moist eczema. 

The fluid which pours forth in vesicular eczema is not 
to be distinguished from ordinary serum; microscopically it 
offers no peculiarities. It is a clear, yellowish, syrupy fluid, 
of a sticky nature, and, as is well known, has the property 
of staining and stiffening linen. When exposed to the air it 
rapidly dries and forms crusts of a yellowish color. 

The alterations which are found in chronic eczema are 
of another character, and differ somewhat according to the 
stage of the disease. The skin here is subacutely inflamed; 
is very much thickened, hardened, and infiltrated with cells. 
The papillae are enlarged, often greatly so, and at times may 
be distinguished with the naked eye. The cell infiltration, 
extends throughout the entire corium, even into the subcu- 
taneous connective tissue. This infiltration occurs diffusely 
in the tissue of the corium, and also about the vessels. Pig- 
mentation may take place in the deep layers of the rete, and 



174 EXUDATIONS. 

in the corium, especially about the vessels. In a typical case 
of chronic eczema of the scrotum, Neumann* found the 
papillae considerably larger than normal, and not only their 
bloodvessels, but also the loops of the lymphatics, elongated, 
the latter being dilated in the form of a flask. Nowhere in 
the course of the lymphatics was there to be found any cell 
proliferation, such as existed about the adventitia of the 
bloodvessels, although the corium was in part displaced by 
cell infiltration. 

In severe cases of eczema of long standing, the hairs and 
glands may become obliterated. 

In considering the relation existing between the capillary 
congestion and the cell proliferation, Foxf is inclined to the 
view that both cells and vessels play an important and some- 
what independent part, in obedience to a nerve paresis, and 
that the most important element in the production of the 
disease is faulty innervation. IlebraJ has expressed a similar 
opinion concerning impaired innervation, but does not speak 
of the influence of nerve irritation as causing cell prolifera- 
tion. He remarks, in seeking an explanation of the occur- 
rence of the disease, that inasmuch as it may result from 
irritants and varicose veins, it is fair to suppose that the 
direct cause is a disturbance of the circulation, especially in 
the capillaries, causing capillary congestion. Whether this be 
the result of disease of the nerves or of the bloodvessels can- 
not be determined. He further believes that the congestion 
occasions such an excessive exudation of liquor sanguinis 
that it cannot be completely consumed in supplying loss, a 
certain superfluous quantity remaining over and infiltrating 
itself in the cutaneous tissues, especially in the epidermis. 

Diagnosis. — Eczema being the most important of all the 
cutaneous diseases, a very careful study of the subject of 
diagnosis becomes necessary, — the more so when the various 
anatomical lesions which the process assumes are taken into 
consideration. No other disease appears in such varying 

* Lehrbuch der Hautkrankheiten, p. 217. "Wien, 1873. 
f Skin Diseases, p. 173. Amer. ed., New York, 1873. 

X On Diseases of the Skin, vol. ii. p. 140, New Syd. Soc. translation. 
London, 1868. 



ECZEMA. 175 

forms. At one time an erythema, either with or without 
desquamation, followed, perhaps, by a weeping surface and 
crusts; in another case, a vesicle, passing rapidly into a pus- 
tule ; again papules, which, when aggregated, may break 
down into a patch, accompanied by moisture; finally, one 
or all of these primary lesions may occur in the same 
patient, presenting a complete picture of this wonderfully 
protean skin manifestation. Add to this the secondary 
changes which always occur, and it will be readily perceived 
how difficult the diagnosis of eczema at times becomes. To 
understand thoroughly the affection it should be viewed as 
a whole, when it will be noted that it always presents cer- 
tain characteristics, some of which are invariably at hand. 

These may now be referred to. 

A certain amount of cell infiltration is always present in 
eczema. It may be very marked or only slight, according 
to the seventy of the process. It may be detected by the 
thickening of the skin, which may be both seen with the eye 
and felt with the finger. Swelling and oedema also exist in 
all acute eczemas, and often in the more chronic cases. The 
patch is red and congested, the redness disappearing slowly 
beneath pressure, and returning in like manner. The exu- 
dation of fluid or plastic material is a constant symptom of 
eczema, and is observed in varying degrees. 

In the vast majority of cases, fluid exudation, or moisture, 
has taken place at one stage or another of the disease. This 
symptom is peculiar, and is characterized as an oozing of 
serum, in varying quantity, which discharges quite uniformly 
from the surface; it is very properly termed weeping, dis- 
charging, or running. Wo other disease has this symptom. 
It may be of the nature of a clear yellowish fluid or puriform ; 
it niay also contain blood. 

The plastic exudation, on the other hand, constitutingthe 
papule of eczema, is more difficult of recognition, and may 
be mistaken for other forms of disease, to be presently re- 
ferred to in detail. Slight desquamation succeeds the typical 
papule. 

Following discharge come crusts, and those of eczema can- 
not possibly be confounded with others. When the discharge 






170 EXUDATIONS. 

has been copious, as is commonly the case, the crusts form 
rapidly and in great quantity; they are yellow, brown, or 
greenish in color, and adhere to a moist surface beneath. 
The amount of cleansing modifies the formation of crusts. 
They are frequently so abundant as entirely to mask the 
skin itself. 

Of the diagnostic subjective symptoms that of itching is 
characteristic. It is of an intense character, far exceeding 
that of other diseases. It is a constant symptom, never 
being altogether absent, although its degree may vary. 
Burning sensations are also always complained of in the 
acute stage, which soon give way to the more decided feel- 
ing of itching. With the itching of eczema there is always 
an irresistible inclination to scratch ; so strong, indeed, as 
not to be denied. 

Finally, it must not be forgotten that two or more varie- 
ties of the disease may be present at the same time upon 
one patient, offering a mixture of lesions in various stages 
of development. 

The diseases with which eczema is liable to be confounded 
may be referred to. 

Scarlatina. — There may in certain cases be difficulty in 
distinguishing it from this disease ; rarely, however, for the 
general symptoms of systemic disturbance in scarlatina are 
so marked as to be very significant. There could be doubt 
only in those cases of acute eczema where the eruption is 
universal, or diffused, occupying the greater part of the body. 
A very short period would in such instances serve to decide 
the question. 

Erysipelas. — Here, however, is an affection with which 
it is more apt to be confused, and which may at times re- 
semble eczema erythematosum or vesiculosum, particularly 
when about the face. The points of difference are numerous 
and patent. Erysipelas is an acute affection, commencing at 
a point and extending itself on the periphery as a creeping 
disease. The inflammation of erysipelas is a deep one, in- 
volving the subcutaneous tissues as well as the skin, and is 
attended with great heat, swelling, and oedema. The disease 



ECZEMA. 177 

is accompanied by symptoms of fever and other general dis- 
turbance. The sensations are those of burning and fullness. 
The skin is deep red, shiningj and tense; there is no dis- 
charge except from the bursting of bullae, which are often 
present in the latter stage of the affection. 

Erythema Simplex. — Eczema can scarcely be mistaken for 
any of the simple erythemas, or, more properly speaking, hy- 
peremias, this being their pathology, for in these disorders 
there is no exudation of any kind, hyperemia, without in- 
flammation, being the sole morbid condition. Eczema, how- 
ever, at times may bear some resemblance to the exudative 
erythemata, and, in particular, to a variety of urticaria. 

Urticaria. — The peculiar form of this affection known 
as urticaria papulosa presents lesions looking very much 
like eczema papulosum, especially in children, which fact 
has given rise to the term lichen urticatus, a disease which, 
however, must be viewed as an urticaria. None of the other 
varieties of eczema can be mistaken for urticaria. 

Herpes. — In their early stages zoster and eczema may 
bear considerable resemblance, although the irregular dis- 
tribution of the vesicles of eczema will usually serve to 
distinguish it from the peculiar and constant symptom of 
grouping in zoster. Eczema is never attended with the 
violent neuralgic pain which always accompanies zoster, — a 
feature in itself quite sufficient to prevent any confusion in 
diagnosis. 

Eczema vesiculosum is much more apt to resemble other 
varieties of herpes, especially those forms occurring about 
the face and genitalia. These, however, run their course in 
a few days as very simple and mild disorders. 

Pemphigus. — Eczema will never be confounded with typi- 
cal pemphigus vulgaris, for here the bullae are isolated and 
large, and have a very different history from the vesicles of 
eczema. There is, however, a variety of pemphigus, known 
as pemphigus foliaceus, which has certain features in com- 
mon with eczema. It is extremely rare, and differs from 
eczema in its history, course, and symptoms. 

Seborrhea. — Squamous eczema bears many points of 
close resemblance to this affection. The two diseases very 

12 



178 EXUDATIONS. 

often present similar appearances as they occur upon the 
seal p. In this region they may even at times exist together, 
the seborrhoea existing as a secondary disorder, having been 
provoked by the eczema. They are nevertheless entirely dis- 
tinct diseases, and it is of the utmost importance to diagnose 
them when they occur separately. 

In eczema the scales are larger, less abundant, and drier 
than in seborrhoea. In eczema.they are, moreover, usually 
seated upon a circumscribed patch, while in seborrhoea they 
cover the scalp quite uniformly. The skin in eczema is 
more or less red and inflamed and always itchy; in sebor- 
rhoea it is apt to be paler than normal, and may or may not 
be itchy. The history of the two affections in most cases is 
sufficiently different to render the diagnosis clear and posi- 
tive. They are both common affections. 

Psoriasis. — Here also is a common disease often con- 
founded with eczema, the appearances very frequently being 
so alike that it becomes a matter of difficulty to decide upon 
the case. Both diseases attack all parts of the body ; both 
are prone to occur on the scalp, where trouble in diagnosis 
is apt to arise. Typical eczema can never be mistaken for 
psoriasis, but old, infiltrated, inflammatory, scaly patches 
frequently look very much like psoriasis. 

The edges of patches of eczema usually fade away into the 
healthy tissue ; in psoriasis they terminate abruptly. The 
scales upon eczematous patches are thin and scanty; in 
psoriasis they are always abundant, and are observed to be 
large, silvery, and imbricated. In eczema there is usually 
some account of moisture at one stage or another of the 
patch; in psoriasis it is always dry. The occurrence of the 
disease on other parts of the body will further serve to 
clear away any doubt, while the general history of the two 
diseases will also assist materially in arriving at a correct 
diagnosis. 

Lichen Planus.— Eczema may be confounded with this 
rare disease. The distinctive features of eczema, however, 
should be remembered ; they will prove sufficient to establish 
the diagnosis. The papules of lichen planus are flat, and 
have an angular base; those of eczema are acuminated, and 



ECZEMA. 179 

have a round base. Those of eczema are bright red in 
color; those of lichen planus have a dull crimson hue, with 
a shining aspect. The papules of eczema form quickly, and 
are apt to undergo change; those of lichen planus form 
slowly, and never exhibit any other form ; they remain 
papules throughout their entire course. Lichen planus dis- 
appears slowly, and leaves stains in the place of the papules; 
papular eczema leaves but little pigmentation. In eczema 
the general health is not seriously affected; in lichen planus 
it is usually greatly disturbed. 

Pityriasis Rubra. — This is even a rarer disease than lichen 
planus, and presents symptoms which might readily be inter- 
preted as eczema. It may be distinguished from eczema by 
its uniform redness; great masses of large, thin, papery, 
whitish, epidermic scales which continually reproduce them- 
selves; abrupt termination of the edges of the disease ; slight 
itching; burning heat; and lastly, by the absence of infil- 
tration and thickening of the skin, a symptom so common 
in eczema. It undergoes very few changes throughout its 
course. 

Tixea Circixata. — This affection is not unfrequently con- 
fused with eczema squamosum. The course of the two dis- 
eases, however, is very unlike, and should alone be enough 
to separate them. Eczema has no tendency to assume cir- 
cular patches; tinea circinata always has. In eczema there 
is no history of contagion ; in tinea circinata the disease may 
almost invariably be traced to this source. The edges of 
patches of eczema seldom terminate abruptly ; those of tinea 
circinata always do. Eczema squamosum tends to run a 
chronic course; tinea circinata an acute one. The itching 
in eczema is always marked, and usually severe; in tinea 
circinata it is not usually a very prominent symptom. The 
microscope reveals the existence of a fungus in the scales of 
tinea circinata.* 

Sycosis. — Both varieties of this affection, parasitic and 
non-parasitic, bear some likeness to eczema of the beard; 

* The differential diagnosis of tinea tonsurans and eczema of the scalp 
will be given in speaking of eczema of the head. 



180 EXUDATIONS. 

but the diseases are in most respects so entirely different as 
to be easily separable.* 

Tinea Favosa. — The yellow crusts of eczema very often 
simulate those offavus, and mistakes in diagnosis may quite 
readily occur unless attention be given to diagnostic marks. 
The crusts of eczema pustulosurn upon the body can scarcely 
be mistaken for favus. Upon the scalp, however, a common 
seat of both diseases, there is much more liability of falling 
into error.f 

Scabies. — This affection possesses more features in common 
with eczema than any other disease. The contagiousness 
of the disease must be one of the strongest arguments 
against the likelihood of the case being eczema. A history 
of direct contagion is usually to be found in scabies. Inflam- 
mation, papules, vesicles, pustules, and crusts are all at hand 
as in eczema, and these lesions therefore are of little assist- 
ance in arriving at the diagnosis. The presence of the acari, 
as proved by the burrow or by extraction with a needle, must 
of course at once settle the question. But the demonstration 
is not always practicable, for in old cases all signs of the bur- 
rows have been destroyed, and the insect is no longer to be 
caught. The regions of the body attacked offer valuable 
hints for diagnosis. Eczema is rarely so diffused as scabies; 
nor does it show itself in preference so markedly about the 
hands and fingers, axillae, abdomen, mammae, nipples, penis, 
and buttocks, all favorite localities for the exhibition of 
scabies. The itching of eczema is usually more violent 
than that which occurs in scabies. In scabies which has 
existed for some time, the whole body will be seen to be 
quite generally involved, the scalp, however, remaining free. 
Patches of disease are not formed in scabies, unless the 
process has been permitted to run on for a long time, when 
they may be produced by prolonged scratching. Scratching 
and strong applications both contribute largely to mask the 



* The diagnosis will be found more in detail in the consideration of eczema 
of the face. 

f The differential diagnosis of these diseases will be found in connection 
with eczema capitis. 



ECZEMA. 181 

original lesions of scabies, and to render the condition sim- 
ilar to eczema. In cases of doubt, the diagnosis may be at 
once decided by treatment. If the disease be scabies, para- 
siticides will soon afford relief and subsidence of the more 
active symptoms ; eczema, on the other hand, will, as a rule, 
not be improved by such treatment. 

Artificial Inflammations. — Various grades of disease, 
produced by means of cutaneous poisons, acids, alkalies, and 
similar substances, often cause true inflammation of the skin 
and subcutaneous tissues, which may present an appearance 
very much like acute eczema. The regions affected; the dis- 
tribution of the eruption; the uniformity and peculiar char- 
acter of the lesions; and the artificial look which always 
accompanies these diseases, afford an insight as to their real 
nature. If suspected, the history, course, and termination 
will always serve to distinguish them from true eczema. 

Syphilis. — Eczema of the scalp is more apt to be mistaken 
for syphilis than any other local variety; upon the body it 
can scarcely be confounded with syphilis. A form of syph- 
ilis occurring at time's upon the scalp looks very much like 
ordinary eczema pustulosum with fissures; it will be found, 
however, upon close examination, to be syphilis of a super- 
ficial ulcerating form, covered by eczematous-looking crusts. 
It will have a strong and disgusting odor, which symptom 
alone will serve to distinguish it from eczema. 

In eczema it is very necessary, in all cases, to remove 
crusts, and other secondary matter, before pronouncing diag- 
nosis; much error will be avoided by attention to this point. 
The other varieties of eczema, the papular and vesicular, 
cannot well be mistaken for syphilis. The subjective symp- 
toms, especially the itching, are absent in syphilis. 

Treatment. — In the consideration of this portion of the 
subject it is necessary, to state that the outlines only for 
treatment can be given. To enter upon the matter fully 
would carry the chapter beyond the space assigned to it. 

Eczema is a perfectly curable disease. For its relief two 
distinct methods of therapeusis are employed, one directing 
all its force against the skin itself, as the offending organ, 
trusting by this means alone to restore health to the part; 



182 EXUDATIONS. 

the other endeavoring to remedy the disorder by the em- 
ployment of internal or constitutional remedies, intended to 
act against the real or supposed source of the disease. The 
plan which appears to me to be the correct one, and which 
in my experience has proved most satisfactory, is that which 
recognizes both local and constitutional remedies as being 
of equal value. I am confident, viewing the matter in a 
broad lisfht, that this doctrine affords us the best results in 
practice. 

Constitutional Treatment. — Constitutional remedies, if 
judiciously prescribed, prove of decided benefit in the great 
majority of cases. They are, however, not demanded in 
every case, and, unless indicated, are not to be recom- 
mended. Great discrimination in this matter is to be 
exercised. 

The subject of diet must in the first place be referred to. 
During an attack of eczema it is important that the diet be 
of a good and nutritious quality. In those cases where the 
natural habit is full, the food should be plain. If there be 
any disturbance of the digestive tract, all those articles of 
food which are difficult of digestion — as, for example, pastry, 
cakes of all description, gravies and sauces, pork, cabbage, 
pickles, cheese, beer, wine, etc. — are to be interdicted. 

Exercise and fresh air are in all instances beneficial ; not 
infrequently they will be found to be invaluable adjuvants 
in the treatment. 

The state of the bowels is to be noted; constipation should 
not be permitted to exist; the bowels should be open at least 
once a day. 

Dyspepsia, in any form, should receive prompt attention, 
and every means employed to remedy the condition. Cer- 
tain eczemas are both brought on and kept up by this state. 

The condition of the kidneys often requires investigation ; 
if there be deficient excretion, it should be remedied. Diu- 
retics are frequently of service. 

Having mentioned in a general way a few of the more 
prominent points for treatment, the various remedies which 
are found to be of service may be spoken of. Laxatives 
are of value in many cases, particularly in the highly inflam- 



ECZEMA. 183 

matory varieties of the disease. Saline aperients especially 
are to be recommended; among these the sulphate of mag- 
nesium occupies a conspicuous position. It may be combined 
to advantage with iron, as in the following prescription : 

R Magnesii Sulphatis, ^i ; 
Ferri Sulphatis, gr. iv; 
Aquae, f^iv. 
M. — Sig. Tablespoonful, 
with a gobletful of water, a half hour before breakfast. 

The laxative mineral spring waters — as, for example, the 
Hathorn and Geyser springs of Saratoga, Friedrichshall 
water, and waters possessing like properties — are exceed- 
ingly beneficial in many cases. 

In infantile eczema, in those instances where the bowels 
are irregular, great good will often be obtained from the 
employment of syrup of rhubarb in repeated small doses. 

"Where there is a coated tongue, with heavy breath, light- 
colored evacuations, and constipation, small doses of calomel 
may very often be administered with good result. At the 
commencement of an acute attack of eczema, cases not in- 
frequently require remedies directed against disorders of 
the stomach, bowels, and secretions. Derangements of this 
character must first be rectified, after which other remedies 
may be prescribed. 

Eczema occurring in old persons, especially in those of a 
gouty or rheumatic disposition, or in those who are bon- 
vivants, may often be very successfully treated with diuretics 
and alkalies ; the acetate of potassium, in full doses, the 
alkaline natural spring waters, and the lithia waters, are all 
useful remedies. 

If the patient possess a debilitated constitution, manifest- 
ing signs of imperfect nutrition or the so-called scrofulous 
disposition, cod-liver oil will prove a valuable remedy. It 
is, I am sure, of service in many cases of eczema, and par- 
ticularly in children. 

The preparations of iron are also to be recommended; the 
syrup of the iodide, the tincture of the chloride, the car- 
bonate, the pyrophosphate, and the wine, are all useful. To 



184 EXUDATIONS. 

obtain good results from the use of iron it is essential that 
the remedy be continued for some time. 

Arsenic is of unquestionable benefit in many cases, but, 
as I have remarked elsewhere (see Part I., Treatment), it is 
very important to select the case, as well as the time for 
its administration. Given to examples of eczema indiscrimi- 
nately, as they present themselves for treatment, it will prove 
of far more injury than benefit. In no cutaneous disease is 
more discretion called for in the employment of arsenic than 
in eczema. It should never be prescribed if there is any 
disorder of the digestive system. It should never be given 
in the acute stage of the disease; it will do at this time 
more harm than good. It is found to be of value in the 
chronic papular form of the affection ; also in the late 
squamous stage. 

Tar has been used internally with benefit in the squamous 
stage of the disease, especially in chronic cases. Sulphur 
spring waters, of which there are great numbers in our 
country, also, without doubt, not infrequently prove ser- 
viceable. 

For washing purposes ordinary water may be employed; 
in those cases where the skin is delicate, distilled water or 
some of the mucilaginous waters, made from bran or flour, 
may be substituted. Ablutions may be used either hot or 
cold, as may be most agreeable to the patient. Too frequent 
washings or general baths are to be avoided; they have a 
tendency to macerate the already morbid epidermis. For 
cleansing purposes both the soda and potash soaps are made 
use of. In the majority of instances ordinary castile soap 
suffices; where the crusts are firmly adherent to the skin, or 
are piled up in masses, the potash or soft soap may be 
resorted to. 

Local Treatment.— The treatment of eczema by means of 
local remedies is of great importance, and demands attentive 
consideration. Very many cases may be relieved by external 
means alone. External treatment, of one kind or another, 
is called for in all cases of the disease. There are no cases 
in which it may not be used w r ith advantage. 

It is a matter almost essential to successful treatment that 



ECZEMA. 185 

the part affected be seen by the physician. It is in the first 
place to be determined whether the disease is acute or 
chronic, whether the process is in its most active stage or 
whether it has somewhat subsided. 

The variety of the disease next presents itself for consid- 
eration ; the primary lesions are to be sought for and exam- 
ined, and the presence of erythema, papules, vesicles, or 
pustules established. The stage in which the affection exists 
is to be noted. The amount of cutaneous disturbance, heat, 
redness, swelling, oedema, and other abnormal phenomena, 
are all to be noted. The condition of the epidermis, whether 
intact or lacerated and torn, should be examined into. The 
character of the crusts and scales is of significance ; the 
presence or absence of fissures should also be observed. 

A question of moment, to be ascertained before instituting 
treatment, is the extent of surface involved; the whole 
body may be affected, or there may be only a single patch. 
The region attacked must also be taken into account. 
Finally, the duration of the disease, its general history as 
stated by the patient, and, in particular, whether a first 
attack or a relapse, are all matters of consequence. 

In all cases of eczema there are present certain secondary 
products requiring immediate removal. These consist of 
crusts, scales, and extraneous matter, which have been al- 
lowed to collect upon the surface. They are to be removed 
before active remedies can be advantageously applied. 
Crusts, if extensive, are to be treated first with oily prepara- 
tions until saturated and loosened, or they may at once be 
acted upon by water and soap or other alkaline washes. The 
thorough cleansing of the part is a point of the greatest im- 
portance, and, unless insisted upon by the physician, will 
rarely be properly performed by the patient or attendant. 
Not uncommonly, repeated applications of oil, followed by 
abundance of soap and water, are required to secure the 
desired end. Scales are removed without difficulty by the 
same means. Water and soap have thus far been alluded 
to only as means for cleansing the skin. I shall speak pres- 
ently of their uses as curative agents. 

Acute Eczema. — Caution is to be observed in prescribing 



186 EXUDATIONS. 

for the acute eczemas. Remedies which are well tolerated 
at a later stage of the disease will, as a rule, now be found 
to be too stimulating. Whatever the remedy applied, it 
should he at first used over a small surface, in order to ascer- 
tain whether the effect be beneficial or otherwise. 

Among the many local sedatives which from time to time 
have been recommended for the early stages of eczema, with 
a view of relieving the highly inflammatory symptoms, and 
the intense itching and burning sensations, I shall mention 
those only which are of most value. It will, however, be 
borne in mind that a preparation which has been of service 
in one case will not necessarily afford relief in another case, 
bearing even, perhaps, the same general features; peculiari- 
ties of skin have much to answer for. If, therefore, one 
remedy does not succeed, another must be tried; and here I 
would remark that it is often extremely difficult to decide 
whether this or that prescription is best suited to the case at 
hand. The patient soon determines this question by the 
amount of ease obtained ; for this is the chief end to which 
treatment in this stage of the affection is directed. 

In acute vesicular or erythematous eczema no soap or 
water should be employed; the parts should not be washed, 
for in the majority of instances water irritates the skin. In 
the place of washing, the surface may be powdered from 
time to time with a dusting powder composed of starch and 
small quantities of oxide of zinc and powdered camphor : 

R Pulv. Amyli, ^vi ; 

Pulv. Zinci Oxidi, spss; 

Pulv. Camphorae, ^ss. 
M. — Sig. Dusting powder. 

Powders of this description may also be made with lyco- 
podium dust, French chalk, carbonate of zinc, and carbonate 
of magnesium, in varying proportions, with or without starch. 

Instead of powders, lotions may be employed. I am in 
the habit of treating many cases of acute vesicular eczema 
with lotio nigra and oxide of zinc ointment, according to the 
following plan, originally suggested to me by Dr. White, of 
Boston. 



ECZEMA. 187 

The affected part is to be bathed with the lotion, applied 
by means of a sponge or a piece of cloth, for fifteen minutes 
at a time, and at intervals of a few hours or longer; the sedi- 
ment should be permitted to remain on the skin. After the 
application, a small quantity of oxide of zinc ointment is to 
be rubbed gently over the part. As a rule, the itching and 
burning are greatly relieved at once, and the disease is very 
often arrested in its course. 

A lotion consisting of lead water, eight ounces; glycerine, 
one ounce, will often be found useful. 

Carbolic acid, a drachm; glycerine, an ounce; distilled 
water, a pint, I can also highly recommend; the strength 
may be increased or diminished according to the effect pro- 
duced. 

Dilute hydrocj-auic acid is also a valuable sedative, as in 
the following formula : 

R Acidi Hydrocyanic! dil., f^iv ; 

Glycerinae, f^i ; 

Aquse Destillatse, Oi. 
M. — Sig. Lotion. 

Fox speaks well of the following: an ounce of finely levi- 
gated calamine powder; two drachms of glycerine ; half an 
ounce of oxide of zinc; and six ounces of water. To be 
applied frequently, by means of a sponge, allowing the pow- 
der to remain upon the skin. 

Weak alkaline lotions, as, for example, one drachm of 
bicarbonate of sodium to eight ounces of water, may also 
be tried in cases where the itching is obstinate. 

Cloths steeped in hot water, and wrung out and applied to 
the parts, at times afford great temporary relief from the 
violent itching symptoms. 

In many cases, ointments seem to answer better than 
lotions. The oxide of zinc ointment is a well known and 
excellent preparation, admirably adapted for many cases ; it 
may be employed either alone or with other remedies. If it 
be benzoated, only a very small quantity of benzoin should 
be used, in order to render the ointment perfectly bland. 
To make it more sedative, a drachm of spirit of camphor 



[88 EXUDATIONS. 

may be added to the ounce, as originally recommended by 
Wilson. 

The subnitrate of bismuth is also serviceable in the form 
of an ointment, as in the following prescription : 

R Bismuthi Subnitratis, £ss ; 

Ungt. Simplicis, ^viiss ; 
M. ft. ungt. 

Where a soft ointment is required, a drachm of glycerine 
may be added with advantage to the above. 

Camphor may also be employed in the form of an oint- 
ment, alone or with oxide of zinc and glycerine. The ap- 
pended formula makes an acceptable, softish ointment, which 
may be used in the first stage of vesiculation : 

R Pulv. Camphorse, ^i ; 

Pulv. Zinci Oxidi, ^ii ; 

G-lycerinae, f ^i ; 

Adipis Benz., gvi ; 
M. ft. ungt. 

Diach} r lon ointment, made according to the formula of 
Iiebra, is a very useful preparation. It is most effective 
when spread upon cloths and applied closely to the skin by 
means of bandages. 

R 01 ei OlivseOpt., fgxv; 

Lithargyri, Jiii, gvi ; 

Aquae, q. s. 
Coque. M. ft. ungt.* 

Olive oil, oil of sweet almond, and dilute glycerine, may 

* The following directions are necessary. The oil is to be mixed with a 
pint of water, and heated by means of a steam-bath to boiling, the finely- 
powdered litharge being sifted in and stirred continually ; the boiling is to be 
kept up until the minute particles of litharge have entirely disappeared. 
During the cooking process a few ounces more of water are to be added from 
time to time, so that when completed water still remains in the vessel. The 
mixture is to be stirred until cool. 

The ointment is difficult to prepare, and requires skillful manipulation. 
"When properly made it should be of a light-yellowish color, and of the con- 
sistence of butter. To insure a good article it is essential that the very best 
olive oil and the finest litharge be employed. 

Messrs. McKelway & Borell, Cramer & Small, and Mr. J. P. Bemington, 
apothecaries, have furnished me, from time to time, with a most satisfactory 
preparation. 



ECZEMA. 189 

also be used as soothing dressings. Likewise, cold cream, 
cucumber ointment, and glycerole of starch. 

In eczema papulosum the inflammation is not diffuse, as 
in the vesicular and erythematous varieties, but is circum- 
scribed, the papules being usually discrete. The inflam- 
mation, consequently, is of quite a different character, and 
pursues, as a rule, a more chronic course. Soothing appli- 
cations are of little benefit here ; more stimulating remedies, 
as the various so-called antipruritics used in the chronic 
stage of the disease, will be found of greater service than 
bland preparations. Carbolic acid, as a lotion, is, I consider, 
the most valuable remedy which we possess for papular 
eczema; its strength should vary from a drachm to two or 
even three drachms to the pint of water. The formula 
already given will be found suitable for many cases. Lotions 
are much to be preferred over ointments for the treatment of 
this variety of the disease. 

It need scarcely be remarked that it is impossible to draw 
the line definitely between acute and chronic eczema, — to 
state exactly when the former passes into the latter. In 
practice, however, it is found that, as a rule, the acute stage 
is very brief, lasting usually from a few days to a fortnight. 
In the selection of remedies the physician must be guided 
rather by the pathological changes which have taken place 
than by the length of time which the disease has existed. 
Some of the remedies, to be referred to presently in speak- 
ing of the local treatment of chronic eczema, may at times 
be used with benefit quite early in the course of the disease. 
I shall, however, refer to this subject again in considering 
the treatmeut of the disease as it attacks particular regions 
of the body. 

Chronic Eczema. — After a few days or longer, the acute 
process will, in most instances, have subsided to a great 
extent, and other remedies will be found more serviceable. 
Crusts should never be permitted to form ; they should be 
removed by the means already indicated. In many cases 
the treatment just referred to for the acute stage serves also 
for later stages; more stimulating applications, however, are 
usually required. 



100 EXUDATIONS. 

Carbolic acid, in varying strength, here, as in the acute 
stage, is one of our most useful remedies; it may be em- 
ployed in the form either of lotion or of ointment. In the 
proportion of ten minims to the ounce of ointment it will 
be found serviceable in both vesicular and erythematous 
eczema; it may be combined advantageously with the ben- 
zoated oxide of zinc ointment. It is a valuable antipruritic 
remedy, and constitutes one of the few substances which 
may be relied upon. 

Somewhat similar in effect to carbolic acid are the prep- 
arations of tar, which are the most serviceable of all external 
remedies. To obtain good results they must be handled 
with care; unless used at the proper time, and in suitable 
strength, they serve only to irritate, and when this occurs 
they are to be abandoned at once. Tar is of most benefit 
when the disease has completely reached the chronic stage. 
It is never to be applied in the acute stage, or at any time 
when vesicles are forming. If there is much inflammation, 
swelling, and heat, it likewise should be withheld. The 
more chronic the condition the more likelihood is there of its 
being tolerated. The mode of application, and the strength, 
are to be determined as the disease is upon one part of the 
body or another. Ointments of varying proportions are the 
most suitable means of applying tar, for, in addition to the 
stimulating effect of the remedy, the emollient effect of the 
lard is obtained. The ointment should not be too strong; 
one drachm of the tar to the ounce is usually sufficient. The 
strength may be increased should the part call for more 
stimulation. The two forms of tar commonly used are pix 
liquida and oleum cadinum. They may both be applied in 
the same manner, and have a very similar effect upon the 
skin. 

R Olei Cadini, fgi ; 
Cerati Simpllcis, %i; 
01. Amygdal. Amar., gtt. vi. 
M. ft. ungt. 

This constitutes one of the most elegant of the tarry oint- 
ments. Fluid preparations are better adapted to the scalp 
than ointments. Tar is employed with excellent result upon 



ECZEMA. 191 

the scalp combined with alcohol, as in the appended pre- 
scription : 

R Picis Liquids, fsp ; 
Alcoholis, f^vii ; 
01. Amygdal. Amar., gtt. xv. 
M. — Sig. To be rubbed firmly into the skin. 

In whatever way tar is employed, the part should be well 
rubbed with it twice daily by means of a piece of flannel 
rag. The ointment should not merely be smeared over the 
surface, but firmly rubbed in for ten or fifteen minutes each 
time. A very small quantity should be used for each appli- 
cation, which should be worked into the skin until it has 
been quite consumed. The same directions apply to the fluid 
preparations. Tar is also advantageously combined with 
soap in the treatment of eczema. In the very thick, old, 
leathery patches of chronic disease, equal parts of alcohol, 
sapo viridis, and pix liquida may be applied in the same 
way as the other preparations just alluded to. To produce 
a stronger impression, potassa may be used in place of the 
soap, in the strength of five or ten grains to each ounce of 
the mixture. 

Dr. Bulkley, of New York, has given to the profession a 
valuable alkaline tarry preparation, which possesses the ad- 
vantage over the usual plain tar in that it combines with 
water, and can be diluted to meet the requirements of the 
case. The following is the formula: 

R Picis Liquidae, f 5pi ; 
Potassae Causticse, gi ; 
Aquae Destillatae, f^v. 
M.* — Sig. " Liquor Picis Alkalinus." To be used diluted. 

It may be used in the form of a lotion or with ointment. 
As a lotion it is to be diluted with water, — from one to 
two drachms to the pint, according to the state of the skin 
and the susceptibility of the individual. Care should be 
observed not to make the mixture too strong at first, for it 
will be remembered that it possesses a large proportion of 

* The potassa is to be dissolved in the water, and gradually added to the 
tar with rubbing in a mortar. 



192 EXUDATIONS. 

caustic potash, which may act injuriously upon the skin. I 
have seen very awkward results from its injudicious use. In 
infiltrated, localized patches it can, of course, be employed 
much stronger, as, for example, one part to five or ten of 
water, followed by the use of some ointment. Bulkley 
recommends in these cases an ointment of tannic acid, a 
drachm to the ounce. 

The liquor picis alkalinus may also be combined with 
ointment, from one to two drachms to the ounce. 

Various soaps are employed in the treatment of eczema. 
Common hard or soda soap, of which the variety known as 
castile is the type, may be used for purposes of ordinary 
cleansing, but to obtain stronger detergent effects the potash 
soaps are brought into requisition, and perform a very im- 
portant part in the handling of certain eczemas. It must be 
remembered that all soaps are more or less alkaline, as they 
are hard or soft and according to their quality, and that 
unless ordered judiciously they may be productive of much 
mischief. This remark applies particularly to the strong 
potash soaps known under the names of sapo mollis, sapo 
viridis, black soap, brown soap, and soft soap, which contain 
a certain amount of free alkali. 

Sapo viridis has numerous uses in eczema. It may be 
employed alone or with alcohol in the form of an alcoholic 
solution. (See p. 113.) 

. It is an indispensable detersive agent, and may frequently 
be applied to cleanse patches of their crusts and scales 
previous to the use of other remedies.* 

It is in the condition which has been described under the 
name of eczema rub rum that sapo viridis is found of great- 
est value.f It is in these cases employed systematically and 

* In order to secure uniform results from the use of the soap, it is well to 
make use always of an article which is known to possess a definite strength. 
That manufactured by Duvernois, Stuttgart, Germany, contains about twenty- 
five grains of uncombined caustic potash to the ounce. It is the most reliable 
soap of the kind with which I am acquainted. It is imported by Messrs. 
McKelway & Borell, and Mr. J. P. Remington, of this city. 

f To Hebra belongs the honor of having been the first to institute the 
method of treatment about to be described. Its worth is scarcely to be over- 
estimated. It is, I think, one of the most important contributions that has 



ECZEMA. 193 

in conjunction with an ointment. The more localized the 
disease the better are the chances for success; in fact, it may 
be stated that, as a rule, this plan of treatment is to be 
adopted only in cases where the disease is confined to one 
or several patches. AVhere the eczema is diffused, and is 
upon various parts of the body, other methods answer better. 

In those frequent, old eczemas of the legs, it is the treat- 
ment par excellence, and effects changes which are striking 
and often surprising. It may be relied upon in these cases 
when all other remedies have failed. It is also to be directed 
in certain other local forms, as, for example, in infiltrated 
eczemas of the hands and arms, in chronic eczemas of the 
face, and, indeed, at all times where the affection is localized 
upon a particular region. 

The treatment consists in the application of the soap, fol- 
lowed immediately by the use of an oily ointment. Soap 
applied alone, in any form of eczema, acts as a mild caustic 
and as an irritant, and tends only to increase the disease. 
This is a point never to be lost sight of; very much damage 
is often inflicted by the indiscriminate and too free use of 
strong soap in eczema. The ointment used in preference 
by Professor Hebra, and the one which is unquestionably 
the best, is the diachylon ointment already spoken of.* 

The accompanying instructions are to be implicitly ad- 
hered to. 

A small lump of the soap, the size of a nut, is smeared 
upon a piece of wet flannel; this is to be applied directly to 
the patch of disease, and rubbed firmly aud with moderate 
pressure upon the skin until all traces of the soap have clis- 

ever been given to cutaneous therapeutics. To have it prove successful it is 
essential that the instructions for its proper performance be faithfully carried 
out. 

* In addition to the method given for its preparation, it may also be made 
with four parts of diachylon plaster and two or three parts of olive oil, the 
two substances being melted, and stirred until cool. The proportion of the 
oil necessary to produce a firm ointment will vary with the consistence of the 
plaster; the older and harder the plaster, the more oil will be required. The 
ointment, however, resulting from this process of manufacture is somewhat 
different from the former ; it is apt to be more stringy, although none the 
less effective on this account. 

13 



104 EXUDATIONS. 

appeared. The piece of flannel may now be dipped into 
warm water and again applied in the same manner to the 
part, when an abundant lather will be formed. More water 
from time to time may be added, until copious suds cover 
the skin, when with clean water the diseased surface is thor- 
oughly washed oft", freed from all signs of soap, and carefully 
dried with a soft cloth or towel. The rubbing should be 
performed with a certain amount of force, to be regulated 
by the amount of infiltration, the region affected, and the 
sensibility of the skin. 

The time occupied in the process also must be governed by 
the effect produced; in slight cases five minutes may prove 
sufficient, while in thick infiltrations, especially upon insen- 
sible regions of the body, ten or even twenty minutes may 
be advantageously expended at each operation. The first 
application should always be somewhat moderate, that too 
great a destruction of epidermis be not produced, thereby 
causing soreness. The sensations of the patient will, how- 
ever, always serve as a guide upon this point. The appli- 
cation is not painful, as might be supposed, but, on the 
contrary, is usually exceedingly agreeable, destroying that 
peculiar symptom of itching so annoying and characteristic 
of the disease. It at once affords ease to the patient, who 
generally expresses himself pleased with the operation. 

The part immediately after the washing presents an in- 
flamed, red, and angry appearance; the skin is clean, tense, 
and shining, showing the epidermis to be very thin and im- 
perfectly formed. Here and there minute puncta may be 
seen, from which clear serum oozes out in pin-point drops. 

The part is now ready for the ointment, which should be 
prepared before the washing is begun, so that no time may 
be lost in applying it, for no delay is permissible in this stage 
of the operation. The ointment is to be spread with a large 
spatula or knife upon strips or pieces of soft, flexible muslin, 
which have been cut to the size of the patch or extent of 
diseased surface. It is not well to make one large piece 
cover the whole, but is preferable to have several pieces, iu 
order that they may be the better adapted to the skin. The 
ointment should be spread quite thickly upon the rags, as 



ECZEMA. 195 

thick as the back of an ordinary table-knife. The part is 
now to be enveloped with these cloths in a neat manner, so 
that no folds or wrinkles may occur, taking in the whole 
surface which has been subjected to the soap. It is more 
prudent to apply the ointment too freely than too scantily. 
Finally, the part should have outside cloths applied, to pre- 
vent the oil from oozing through, and be bound down by 
means of strips or a bandage. The bandage is also a matter 
of moment, for its proper application contributes very mate- 
rially to the success of the treatment. It is essential that 
the ointment be brought into the closest contact with the 
skin, and that it be kept in this position. 

If the region be not very extensive, the patient may be 
permitted to go about as usual, care being exercised that 
the dressings are not disturbed. 

This entire operation is to be repeated in exactly the same 
manner, and with the same attention to minutiae, twice daily, 
in the morning and before retiring. Improvement will be 
noticed at once. The patient will obtain relief from, the 
itching at the first rubbing with the soap, and very decided 
comfort after the ointment has been on for a short time. 
This process is the most effectual means which we possess of 
affording immediate relief from the itching. 

In very extensive and old patches of eczema it is at times 
necessary to have recourse to a more powerful caustic than 
the sapo viridis, in which case a solution in water of po- 
tassa may be applied. The strength may vary from ten 
grains, to a half a drachm or even a drachm to the ounce, 
but extreme caution is necessary in the use of such strong 
remedies, which should in every case be employed by the 
physician himself. The stronger the application the less 
often should it be repeated; once every other day, twice or 
even once a week, will in most cases be sufficient for any of 
the just-mentioned solutions. The effect of the caustic in 
these cases should be moderated by cold water cloths and 
compresses for a time, after which the unguentum diachyli 
may be used as described. 

There are numerous other remedies and modes of treat- 



1 90 EXUDATIONS. 

ment for the chronic stage of eczema, some of which are of 
greal value and may here be referred to. 

The mercurial preparations occupy the first place in the 
list, and will be found exceedingly useful in a great number 
of cases, particularly in those instances in which the disease 
is confined to a small area without tendency to spread. The 
red oxide of mercury, in the form of an ointment, varying 
in strength from five to thirty grains to the ounce, to suit 
the case, is a remedy of very decided value. It is the active 
ingredient of a large number of the nostrums vaunted for the 
cure of all cutaneous diseases. 

Ammoniated mercury ointment, made in the same pro- 
portions as the above, is also a remedy of worth. It is less 
severe in its action than the red oxide, and may be pre- 
scribed with good result in the pustular eczemas of children. 
It is likewise one of the popular remedies. 

The other mercurials — as the corrosive chloride, red iodide, 
nitrate, and bisulphuret — may also be used, care being taken 
not to prescribe them too strong. It must be remembered 
that there is some risk of salivation, even when applied to 
very small surfaces; this it is which necessitates their being 
prescribed with caution. 

Sulphur at times acts with some success, although its value 
is in no degree comparable to that of the mercurials. 

For exceedingly obstinate circumscribed patches of ec- 
zema, blistering with cantharides will be found serviceable. 
A similar result may be obtained from carbolic acid, diluted 
with alcohol or in its pure state; also from nitrate of silver. 

Vulcanized india rubber is a useful therapeutic agent 
in certain cases. In the form of a cloth or sheet, applied 
closely to the part, it serves to protect the skin and to exclude 
the air. In some instances it has a decided curative effect. 
When practicable, it should be employed continuously, day 
and night. It should be removed and cleansed once or twice 
in the course of the twenty-four hours, when the skin may 
be wiped or rubbed dry with a rag, and the cloth re-applied. 

Prognosis. — This must depend very materially upon the cir- 
cumstances attending the case in question. It may, however, 
be stated that eczema is always a curable disease. There 



ECZEMA. 197 

are a number of points which should be taken into consid- 
eration before an opinion is given as to the probable dura- 
tion. The general health and condition are, in the first place, 
to be well investigated; and in this connection the cause of 
the disease is, if possible, to be ascertained. This question 
is one of the greatest importance, upon which the prognosis 
must entirely depend. The variety of the disease is next to 
be determined; whether the elementary lesions appear in a 
regular, definite manner, or whether the process inclines to 
irregularity and polymorphism. 

It is well known that certain varieties of eczema usually 
run obstinate and long courses, while others tend to recovery 
after reaching a certain stage. Acute inflammatory eczema 
vesiculosum, for example, is apt to run a short and definite 
course, while, on the other hand, eczema papulosum is prone 
to be stubborn and chronic. The stage of the eruption is 
also to be taken into account, as well as the duration of the 
disease; further, whether it is a first attack or a relapse. It 
is, moreover, of the greatest moment to ascertain whether 
the disease be acute or chronic; whether the process tend 
to terminate spontaneously, or to run on indefinitely, with 
secondary changes. 

In calculating the prognosis, the location of the eruption 
is also to be considered, for eczema of certain parts of the 
body is almost invariably obstinate. Upon the head and ears 
it is always troublesome, and often tends to be chronic. 
About the nose and mouth the erythematous variety is 
usually very unyielding. Eczema of the scrotum is likewise 
difficult to relieve; at times it is intensely rebellious. About 
the legs in old people, more particularly if complicated with 
varicose veins or ulcers, it is always more or less intractable. 

Local Varieties of Eczema, their Diagnosis and Treat- 
ment. 

Eczema may show itself upon any part of the body. No 
region is exempt. It may manifest itself upon a small por- 
tion of the body only, or it may involve the whole integu- 
ment. When the entire surface is affected, leaving no portion 
of the skin free, it is termed eczema universale, the variety 



198 EXUDATIONS. 

of the disease being in this event either erythematous or 
ular; so extensive a distribution of the disease, how- 
ever, is of rare occurrence. Usually it appears in the form 
of one or more irregularly-shaped patches, varying in size 
from a small coin to the palm of the hand. 

Eczema attacks certain regions of the body in preference. 
Inasmuch as it exhibits peculiarities of appearance and course 
as it is located upon one part or another, it will be necessary 
to give a description of the more common of these so-called 
local varieties of eczema. I shall, at the same time, speak 
of their differential diagnosis and special treatment. 

Eczema Capitis. — Eczema is frequently encountered upon 
the head, especially in children, in the erythematous or pus- 
tular form. The former variety, as a rule, at once tends to 
take on a chronic course, and soon settles into that stage 
which is known as eczema squamosum. The patches are 
usually roundish, and may occur either singly or in numbers 
upon any part of the scalp. The disease may also involve 
the whole head, every part of it being similarly affected. 
The itching is generally very annoying. 

The pustular variety is very common in children, and 
occurs also in adults. It either exists in the form of a few 
patches of pustules, occurring here and there, or, as is more 
apt to be the case, it takes possession of pretty much the 
whole scalp. The pustules usually appear in great numbers, 
for the most part about the hair follicles; they soon rupture, 
and the liquid oozing over the surrounding skin dries and 
forms thick, greenish-yellow crusts. As the process goes on 
and new pustules are produced, which undergo the same 
course, the crusts become thicker and more bulky, until in a 
short time the whole head is completely covered with a cap 
of crust. The hair becomes matted and caked, the sebaceous 
secretion collects, and soon, if the part be not frequently and 
properly cleansed, the head becomes exceedingly offensive. 
In this description we have a typical eczema pustulosum, 
which applies to adults as well as to children. 

The disease may last a few weeks or years, according to 
circumstances. The itching is usually not so decided or so 
violent as in the other varieties ; at times it is slight. 



ECZEMA. 199 

Accompanying severe cases of pustular eczema of the 
head it is common to observe marked enlargement of the 
subcutaneous glands of the neck; they often become very 
greatly swollen, and present a bunchy appearance. The 
condition occurs particularly about the back of the neck, 
where the hair ends, and also back of the ears. They are 
sympathetically affected, and increase and diminish in size 
as the disease is worse or better. They never suppurate, 
but continue until the eczema disappears. Small abscesses 
are often met with upon the heads of unhealthy children, 
which tend to complicate the original affection. 

Pediculi are frequently found in connection with eczema 
capitis, especially in children, either as a primary cause or 
in consequence of the matted condition of the hair, consti- 
tuting a favorable habitat for them. They are a very 
common source of the affection, especially in the heads of 
the poorly nourished and ill cared for, and their presence or 
absence should always be established at once. They are 
very apt to escape notice, owing either to the fact of their 
not being numerous, or to long and thrck hair, which may 
conceal them. Their eggs, or nits, however, are usually to 
be found clinging to the hairs, quite remote from the scalp. 
When present, pediculi are exceedingly mischievous, and 
call for active handling. 

The diagnosis of eczema capitis is at times difficult; it 
may be confounded with psoriasis, seborrhcea, favus, syphilis, 
and tinea tonsurans. 

Eczema may often be distinguished from psoriasis by its 
tendency, during some period of its course, to show moist- 
ure; psoriasis is never moist. In eczema the edges of the 
patches are not abrupt, but fade away into the healthy skin ; 
in psoriasis the patches have defined borders. Eczema is 
apt to show crusts, if there has been any fluid exudation, or 
small, fine scales if in the squamous stage; psoriasis presents 
the typical dry, thick, whitish, mother-of-pearl colored scales. 
Eczema mayor may not involve the head alone; psoriasis 
of the head usually shows signs of its presence upon other 
regions of the body. Eczema of the head commonly occurs 
in the debilitated; psoriasis usually in the robust. Eczema 



200 EXUDATIONS. 

of the head is apt to be much more itchy than psoriasis. In 
doubtful cases, the general history and course of the affection 
may be of service in arriving at a diagnosis. 

Eczema and seborrhcea very commonly bear a close re- 
semblance to each other. Eczema is prone to occur in 
patches; seborrhcea almost always invades the whole scalp 
quite uniformly. The fluid discharge and consequent crusts 
of eczema are to be remembered; in seborrhcea there is no 
discharge, the product being composed of dry, fine scales, 
of an oily nature, which cake together and adhere closely to 
the scalp. Eczema is a much more acute and rapid process 
than seborrhcea, often making its appearance suddenly; 
seborrhcea develops itself by degrees. Eczema is very itchy; 
seborrhcea not to the same extent; often not at all so. Patches 
of squamous eczema are red and infiltrated ; those of sebor- 
rhcea are pale, the same color as the surrounding scalp, and 
are not infiltrated. 

Eczema can only be confounded with tinea favosa when it 
is of the pustular variety; in such cases the two diseases 
may readily be mistaken for each other, as the crusts have 
points in common. In eczema, however, the crusts are the 
result of previous pustules; in tinea favosa the crusts are 
peculiar, having begun primarily as crusts. The crusts of 
eczema are greenish yellow: those of tinea favosa are bright 
yellow ; moreover, they are cup-shaped, rounded, isolated, 
or, if crowded together, tend to preserve their original shape; 
they form very slowly, are perfectly dry, and are remarkably 
friable. The odor about an eczematous head is nauseous; 
about tinea favosa it is characteristic, and is like that of 
mice. The microscope establishes the diagnosis at once, 
the crusts of tinea favosa being composed entirely of fungus, 
whose elements may be readily discovered under a micro- 
scopic power of three hundred diameters. 

Certain late forms of syphilis of the scalp may be mistaken 
for eczema, and in these cases the diagnosis is often difficult. 
The crusts may be very similar, but there are always signs 
of ulceration in syphilis, which are altogether wanting in 
eczema. The ulcers are observed to have abrupt edges, and 
to have unhealthy looking, grayish bases, with an abundant, 



ECZEMA. 201 

thick, creamy secretion. There is no itching of any moment 
in syphilis of the scalp ; in eczema it is usually marked, and 
at times excessive. The odor attached to syphilis of the 
scalp is powerfully penetrating and disgusting; in eczema it 
is peculiar, but not intensely disagreeable. The history of 
the case will be of value in assisting the diagnosis. 

Eczema erythematosum, or squamosum, may readily be 
confounded with tinea tonsurans. The patches of eczema, 
however, are not attended with loss of hair; in tinea ton- 
surans they are, the hairs being broken off uniformly about 
an eighth of an inch beyond the scalp, presenting an appear- 
ance as though the patch had been shaved and the hair had 
been permitted to grow again. The hair has a nibbled ap- 
pearance. The patches of tinea tonsurans are always cir- 
cular; in eczema they are usually roundish, but not well 
defined. The hairs in tinea tonsurans have a dried, twisted, 
brittle appearance, and come out in quantity; in eczema they 
remain firm, unless scratched out by the patient. The scalp 
has a dead, leaden, pale color in tinea tonsurans; in eczema 
it is reddish. The itching in eczema is great; in tinea ton- 
surans it is often slight. A history of contagion is almost 
always to be found in connection with tinea tonsurans. 

The treatment of eczema capitis will depend upon the 
variety of the disease, upon the stage it is in, and upon the 
state of health of the patient. The age of the patient must 
also be taken into consideration. If the case be of the pus- 
tular variety, it is of the first importance to have the crusts 
thoroughly removed ; this is best accomplished by soaking 
the head with olive or sweet almond oil, and then washing 
with warm water and abundance of soap. If the crusts are 
in great quantity and firmly adherent, it will be necessary to 
allow the oil to remain on the head all night, a flannel skull- 
cap and bandage being put over the head to keep it in con- 
tact with the crusts. The use of the oil and the cap should 
be persevered in until the head is perfectly free of crusts. 
In severe acute cases, where the pustules are appearing from 
day to day, the application of oil, in the manner just de- 
scribed, constitutes in itself a very excellent dressing, and 
may be employed at times when other remedies prove too 



202 EXUDATIONS. 

stimulating. Equal parts of glycerine and water, also, will 
be found useful ; to be applied two or three times daily. 

It is rarelj if ever necessary to shave or to cut the hair. 
The operation should never be performed, except upon chil- 
dren, the value of a head of hair, especially for a woman, 
more than counterbalancing whatever slight benefit may be 
derivable from its removal. In young children and in boys, 
however, the hair in severe cases, especially if complicated 
with pediculi, may be cut close, in order that the part may 
be better attended to and the applications more thoroughly 
made. If nits be present in numbers, they, too, may he 
srot rid of more promptly and effectually in this way. In 
inflammatory cases, lotio nigra may be sopped on the scalp 
for ten or fifteen minutes at a time, morning and evening, 
followed by an oily preparation. 

Although ointments are objectionable as applications to 
the scalp, yet obstinate cases occur in which their employ- 
ment seems so beneficial that it is well to sacrifice points of 
minor importance. An ointment composed of one drachm 
of the mild chloride of mercury to the ounce of simple 
ointment will at times be found of value, directions being 
given to use a very small quantity, and to have it rubbed 
in. In cases where washing and frequent cleansing appear 
to increase the inflammation, this proceeding had better be 
omitted for a few days, when the skin maybe in a condition 
again to bear it. The ammoniated mercury in the form of 
an ointment, five or ten grains to the ounce, answers very 
well in cases where the disease is limited; should there be 
pediculi present, it will also serve as an excellent parasiti- 
cide. Ten grains of the red oxide of mercury to the ounce 
of vaseline, I have found most useful in many cases. 

Patches of squamous eczema require a stimulating treat- 
ment similar to that employed upon other portions of the 
body. Liquid preparations are to be preferred to ointments, 
especially if the disease be extensively distributed. The 
most valuable remedies are the tarry preparations, which, in 
one strength or another, will be tolerated in the majority of 
cases; instances, however, are continually occurring where 
they cannot be employed, owing to some peculiarity of the 



ECZEMA. 203 

skin. One drachm of tar or of oil of cade to the ounce of 
alcohol, forms an admirable mixture for the more chronic 
cases, where stimulation is required. A milder preparation, 
composed of a half drachm or one drachm of oil of cade to 
the ounce of oil of sweet almond, is also frequently useful. 
Carbolic acid, with alcohol and castor oil, may also be em- 
ployed, the strength varying with the condition of the scalp. 

Eczema Faciei. — The face is a common seat of eczema. 
The disease here may be either acute or chronic. The ery- 
thematous variety is frequently encountered here in adults, 
in the form of patches about the forehead, cheeks, and other 
regions. The vesicular variety is also very common here, 
especially in children. Where the disease of the scalp is 
extensive, it is apt to spread itself somewhat over the fore- 
head. The surface may be simply red, infiltrated, and 
slightly squamous, or it may show signs of moisture, with 
large masses of crust. 

Eczema occurs much more frequently about the face in 
infants and children than in adults. In young children it is 
the most common seat of the disease. The nose, especially 
about the ala3 and nares, is not an unfrequent situation for 
erythematous eczema in adults; it is usually very stubborn. 
The itching in these latter cases is always severe, and is the 
source of great annoyance. In connection with the nose, 
the upper lip may also be involved. 

Eczema Labiorum. — The disease occasionally attacks the 
lips, either alone or in connection with other parts of the 
face. One or both lips may be affected. The symptoms 
observed are swelling, redness, heat, infiltration, slight scali- 
ness, and fissures. The skin around the mouth may be 
the seat of the disease, or the red of the lips and mucous 
membrane themselves may be attacked. According as one 
variety or another of the disease exists, will the symptoms 
be somewhat different. The mouth may be very much con- 
tracted, and the lips parti} 7 glued together by the exudation ; 
crusts may also be present. The mucous membrane is at 
times involved to such an extent as to be quite devoid of 
epithelium. 

Care must be exercised in the diagnosis, for both herpes 



204 EXUDATIONS. 

labialis and syphilis possess features which may readily be 
confounded with eczema. Herpes always runs an acute 
course, lasting at most only a short period, and, moreover, 
shows itself in the form of a distinct group or groups of 
vesicles. Eczema invades a greater amount of surface, and 
is invariably obstinate in its nature. Syphilis occurring 
about the mouth has a predilection for the angles, where it 
is usually seen to be localized; the fissures are deep, and 
secrete a thick, puriform product. 

The treatment of this variety of eczema is difficult, and is 
attended with much discomfort for the patient. Either very 
strong or very mild applications are found to be of most ser- 
vice. Potassa or nitrate of silver solutions, equal parts of 
carbolic acid and alcohol, tar ointment, and other heroic 
remedies, may be tried; or, on the other hand, it may be 
that more relief is afforded by the emollient ointments and 
lotions, such as equal parts of glycerine and water, oil of 
sweet almond, vaseline, and like preparations. 

Eczema Palpebrarum. — This occurs quite often in children 
of a scrofulous disposition, and shows itself along the edges of 
the eyelids. The hair follicles are involved with small pus- 
tules, which soon burst, and are succeeded by crusts, which 
adhere tenaciously to the hairs and lids. The parts are 
swollen, red, and itchy, and, uuless frequently cleansed, 
tend to glue together. Conjunctivitis may or may not be 
present. The local treatment must vary according to the 
intensity of the disease. If severe, the eyelashes should 
be extracted and the edges touched with a solution of po- 
tassa iu water, ten grains to the ounce, as recommended by 
McCall Anderson. The edges should be carefully dried and 
the lid everted, a very small quantity on a delicate brush 
being applied. The alkali should be immediately neutralized 
with dilute vinegar or acetic acid. The operation may be 
repeated every few days or even every day for a time, after 
which a weak ointment of the nitrate of mercury ma} T be 
used. In mild cases this ointment, weakened, may be em- 
ployed alone with good result. 

Strict rules as regards frequent bathing and careful cleans- 
ing are of importance, without attention to which no speedy 



ECZEMA. 205 

or favorable result is to be looked for. It is scarcely neces- 
sary to add that energetic internal treatment, with hygienic 
measures, is called for in almost all of these cases. 

Eczema Barbae. — When the disease attacks the region of 
the beard it gives rise to great disfigurement, pain, and 
trouble, and is always found to be exceedingly stubborn in 
its course. It is characterized by the rapid and extensive 
formation of pustules, which are situated in preference 
around the hairs. Crusts of a greenish or yellowish color 
are soon formed, which, matting the hairs together, adhere 
firmly to the parts. A portion only, or the whole, of the 
beard may become involved; the latter condition is usually 
observed to exist. The face is very much swollen, while the 
skin has an angry, dark red hue, showing the process to be 
a fierce one. Pain and intense burning and scalding sen- 
sations are present, rendering the affection one of the most 
distressing of all the forms of eczema. The disease may 
run an acute course, but much more frequently it takes on 
chronic action. 

Eczema of the beard may be confined to the hairy por- 
tions of the face, or it may, and often does, extend to other 
regions of the face. In this respect it differs from sycosis 
non-parasitica, which is always limited to the hair follicles. 
As regards the general features, these two affections are 
quite similar, but the difference is always sufficiently clear 
when the various points of distinction are carefully viewed. 
Sycosis is an inflammation of the hair follicles only, — a fol- 
liculitis barbae, — characterized by the formation of papules, 
tubercles, and pustules; the process is a deep one, always 
extending into the follicles themselves. In eczema the 
process is much more superficial, and extends over the sur- 
face, involving the follicles in its course exactly as in eczema 
of the scalp. Tubercles, so common in sycosis, are alto- 
gether wanting in eczema of the beard. The general history 
of the case, which is always of assistance in determining the 
diagnosis, will aid in distinguishing the two diseases. 

Tinea sycosis also resembles eczema barbae, but, remem- 
bering certain symptoms always found in the former affec- 
tion, error can scarcely occur. Crusts are always abundant 



206 EXUDATIONS. 

in eczema; in tinea sycosis they are scanty. The crusts 
being removed, the surface of the skin in eczema is seen 
to be smooth; in tinea sycosis it is always very uneven, 
tubercular, and lumpy. This point I consider of the great- 
est value in diagnosis. The hairs of eczema are not to be 
plucked without pain; they are firmly seated in their fol- 
licles. In tinea sycosis they almost drop out of their own 
accord. The hairs themselves, examined either with the 
naked eye or with the microscope, are found to be very dif- 
ferent; in eczema they are straight, with a luxuriant, glu- 
tinous mass attached to their roots, while in tinea sycosis 
they are always crooked, twisted, and dry. In eczema there 
exists no fungus; it is always present in quantity in tinea 
sycosis, and may readily be detected with the microscope. 
Eczema is not contagious; tinea sycosis* is highly so, and its 
source may moreover often be traced to tinea circinata, 
either upon other parts of the body or to other members of 
the family. 

The treatment, to be effectual, must be energetic and very 
decided; temporizing measures are to be deprecated. 

After all crusts have been taken off by means of poultices 
or warm water and soap, the part is to be cautiously shaved. 
The first operation is apt to be painful, but after this, patients, 
as a rule, do not complain. The beard is to be kept clean, 
shaving being resorted to every day, or every other day, as 
may be necessary. This is a very important part of the 
treatment. The difficulty of bringing the remedies into 
immediate contact with the skin if the stiff hairs are per- 
mitted to protrude will be appreciated. If the process be 
very acute, the method of treatment by means of unguentum 
diachyli and soap, either castile or sapo moilis, may be di- 
rected, the disease being managed in the same manner as 
upon the non-hairy portions of the body. The applications 
may be employed continuously, both day and night, or only 
at night-time. 

The parts are never to be rubbed vigorously, or the soft 
soap applied, unless the ointment is to be afterwards bound 
on. Unless the hairs are loose, from very extensive suppu- 
ration, depilation is never to be practised. In the chronic 



ECZEMA. 207 

stage, stimulating ointments are to be used; but they should 
be mild at first, until the excitability of the skin is ascer- 
tained. The prognosis is only favorable provided the patient 
is able to carry out the treatment faithfully; even under 
these circumstances the cure is often tedious. 

Eczema Aukium. — The ears are a frequent seat of eczema, 
in both children and adults, and may be involved in connec- 
tion with the disease upon contiguous regions, or they may 
alone be attacked. The erythematous, vesicular, and pus- 
tular varieties all occur here. In the acute stage the ears 
become very much swollen, are red and intensely hot, and 
the seat of severe burning and itching sensations. One or 
both organs may be attacked, more commonly both. The 
process often extends into the meatus, causing occlusion and 
temporary deafness. When there are vesicles or pustules, 
crusts form and envelop the whole appendage; in other 
cases, there is great thickening and desquamation in the 
form of flakes or large scales. The meatus, when attacked, 
is usually observed to be affected in this latter manner. 

The diagnosis of eczema of the ears, and especially of the 
external auditory canal, is often overlooked, the condition 
being attributed to other diseases. 

On account of the peculiar anatomical structure of the 
ears, the successful application of remedies is difficult; oint- 
ments, however, will be found most serviceable. The prep- 
arations of tar are of particular value, and are tolerated, in 
the majority of cases, after the acute stage has passed away. 
When the disease is located about the meatus, greater care 
is to be observed in the use of strong remedies, lest the 
application have an injurious effect upon the membrana 
tympani. The canal should be washeVl out by means of a 
suitable syringe, and cleansed of all crusts and scales. If 
the crusts and scales be in quantity and hardened, a drop 
of oil of sweet almond may first be introduced to soften the 
mass. The use of potassa solutions, followed by stimulating 
ointments, as suggested in the treatment of eczema of the 
eyelids, will be found of greatest service. If strong solu- 
tions are employed, especially by means of a syringe, care 
is to be exercised in protecting the drum and in counteract- 



208 EXUDATIONS. 

ing the effects of caustics. Eczema of the ears is usually 
obstinate in its course. 

Eczema Articulorum. — The disease here generally selects 
the flexor surfaces for its seat; the axillae, flexor surfaces of 
the elbow-joints, popliteal spaces, groius, are all favorite re- 
gions for eczema. The disease rapidly passes into the moist 
state, attended by maceration of the epidermis, which is kept 
up either by the motion of the parts or by the rubbing of op- 
posite surfaces. The process is almost always symmetrical. 
In certain of the localities mentioned it passes into the 
condition known as eczema intertrigo, to be presently re- 
ferred to. 

Eczema Genitalium. — These organs are very frequently 
attacked, occasioning most distressing symptoms. In the 
male the scrotum and penis may be involved together, or 
either alone may be the seat of disease. The scrotum is the 
region commonly affected. Owing to the rich supply of 
lymphatics, it is apt to be enormously swollen and cedema- 
tous. Moisture, crusts, and painful fissures are prone to 
occur, followed by extensive thickening and the most intense 
itching. It is an extremely harassing form of the disease, 
and is always very obstinate in character. 

The female organs suffer like symptoms. The labia are 
usually affected; the vagina may also be invaded. The dis- 
ease may further extend to the surrounding parts, including 
the mons veneris and perineum. When the labia are at- 
tacked they are very greatly enlarged and exceedingly cede- 
matous. They become dark red in color, very hot and 
inflamed, and ordinarily discharge freely from their sur- 
faces ; crusts form rapidly, and the opposing surfaces are 
apt to become glued together. At other times no discharge 
takes place, the parts being simply erythematous and slightly 
scaly. The itching is very violent, and occasions intolerable 
misery. The causes of the disease in females are often to be 
referred to uterine disturbances. 

Eczema of the genital organs in either sex at times yields 
easily to treatment, and in other instances is in the highest 
degree intractable. Upon the scrotum, the method by means 
of sapo viridis and unguentum diachyli will often be found to 



ECZEMA. 209 

relieve the symptoms when other means have failed. Po- 
tassa solutions, a half drachm or even a drachm to the ounce, 
may be applied in place of the soap. But these powerful 
caustics are never to be used without counteracting their 
effects by means of water or dilute acids; bland ointments, 
moreover, should always immediately succeed their use. In 
the acute stage of the disease, lotio nigra may be recom- 
mended, to be followed by an ointment of oxide of zinc and 
calomel, a half drachm to the ounce. 

Carbolic acid, in the form either of lotion or of ointment, 
is an invaluable remedy in many of these cases. It may be 
prescribed in the strength of ten or fifteen minims to the 
ounce, either of water or of ointment. Stimulating oint- 
ments may be in turn tried, for it frequently happens that 
one preparation will answer when another of a similar kind 
fails utterly in giving relief. 

Eczema Ani. — This region is sometimes alone attacked; 
in other instances the perineum is also involved at the same 
time. The part becomes red, infiltrated, and thickened, 
either with or without fluid exudation. Fissures, often of 
great size, are present, and pain consequently attends each 
movement of the bowels. The itching and burning sensa- 
tions are of a most persistent and annoying character. The 
disease is increased by the friction of the opposing nates, 
and by the heat, perspiration, and sebaceous secretion, which 
are usually present. 

Great care should be exercised in diagnosing between 
pruritus and eczema. In the former there exists no erup- 
tion, except that produced by rubbing and scratching. Fis- 
sures may occur in pruritus, caused by the inordinate scratch- 
ing and mechanical injuries of one kind or another, which 
those suffering from this affection are apt to inflict upon 
themselves with the hope of obtaining temporary ease. One 
or more of the characteristic symptoms of eczema will 
always be present, and will aid in distinguishing between 
the diseases. 

The treatment is the same as that which has been given 
for eczema of the lips. 

Eczema Intertrigo. — This has been spoken of when cpn- 

14 



210 EXUDATIONS. 

sidering eczema as it appears about the joints. It occurs 
upon the inner surfaces of the nates, along the groins, 
beneath the mammae, and in other localities where folds of 
skin naturally come in contact with one another. A moist, 
macerated surface is the result, which is greatly increased 
by movement, walking, and inattention to cleanliness. It is 
oftenest met with during warm weather. 

Eczema of this description is not to be confounded with 
erythema intertrigo, or chafing, a hyperaemic affection, which 
is common in summer among people of all ages and classes. 
An erythema intertrigo, however, if neglected, may and 
often does pass into an eczema intertrigo. 

The parts should be washed but seldom. Oxide of zinc 
and starch dusting powders or astringent lotions may be 
used to advantage, the opposing surfaces being separated, 
and, if possible, retained in this position by means of lint or 
cloths. But little exercise should be indulged in ; complete 
rest, indeed, and entire attention to the treatment, will go 
far towards modifying the symptoms and relieving the 
affection. 

Eczema Mammarum. — These portions of the body in the 
female are at times the site of a very troublesome eczema, 
which localizes itself, in a circumscribed form, about the 
nipples. One or both may be invaded. It is met with for 
the most part in women who are nursing, but it also appears 
in those who are not nursing, and in single women. It 
ordinarily assumes the vesicular variety, and is attended 
with crusts and extensive fissures. When exposed to the 
sucking of the child, great pain is experienced, so much 
that the mother is compelled to withdraw the infant either 
temporarily or permanently. The disease is always aggra- 
vated by nursing. The nipples in severe cases are observed 
to become retracted and to be sunken in the breast, the part 
being entirely covered with dried exudation and blood crusts. 
The affection is noticed most frequently in primiparse. The 
diagnosis is not difficult. The mammae, it will be remem- 
bered, are usually affected in scabies. 

When practicable, the best and most expeditious treat- 
ment will be found in the sapo viridis and unguentum diachy 



ECZEMA. 211 

method, already described. The parts, though apparently 
tender and sensitive, will tolerate the free use of the soap 
and friction in almost all cases, and after being properly 
dressed will feel greatly relieved. The applications may be 
made once a day, — at night, — or both morning and even- 
ing. Before nursing, the nipples should first be anointed 
with olive oil, to soften the ointment, and then washed with 
castile soap and water. After nursing, the ointment may be 
reapplied. Unless treated vigorously, eczema of the breasts 
is apt to be of a very refractory nature. 

Eczema Umbilici. — This is met with either alone or in 
connection with the disease upon other parts of the body. 
The navel itself may be the only portion involved, or the 
surrounding skin, in the shape of a circular patch, may also 
be affected. Eczema here is usually moist and fissured. 

A disagreeable odor is always connected with the exuda- 
tion, and crusts form and adhere tenaciously to the skin. 
The diagnosis is sometimes rendered difficult by the fact 
that syphilis attacking this locality often closely simulates 
eczema. Ulcers, however, will be encountered in syphilis, 
and the smell, moreover, will be noted to be very offensive. 

The treatment will depend upon the variety of the disease 
present, upon the extent of skin involved, and upon peculi- 
arities in the formation of the navel. 

Eczema Crurum. — The legs are among the most common 
localities attacked, especially in old people, both male and 
female. Eczema here gives rise to a chronic condition 
which may last for years. It appears in the form of the 
erythematous and vesicular varieties, which, however, soon 
lose their distinctive features, passing, as a rule, rapidly into 
the state known as eczema rubrum or madidans. One or 
both legs may be affected. Other portions of the body are 
not apt to be assailed at the same time ; patients may have 
eczema of one . or both legs for a very long period without 
showing any trace of the disease elsewhere. It is rare 
among young persons, but more common as age advances, 
while among middle-aged and old people its occurrence is 
extremely frequent. It shows itself in the shape of one or 
more patches, varying in size, seated in preference upon the 



212 EXUDATIONS. 

anterior surface of the limb. These patches ordinarily coa- 
lesce and form one large, continuous patch, involving the 
greater portion of the leg. When chronic, — the state in 
which it generally first comes under notice, — the leg usually 
presents one or the other of the following appearances. It 
may be deep red in color, covered in part or wholly with 
large, thick, yellow or brownish crusts, discharging here and 
there between the crusts the ordinary fluid, either clear or 
mixed with pus and blood. In places the skin is laid bare, 
the result of scratching, and shows an inflammatory, punc- 
tate, oozing surface. On the other hand, the leg may be 
red, without moisture or crusts, exhibiting a smooth, tense, 
shining, unbroken skin, in the form of patches, or, more 
commonly, one large patch. Both forms of the disease are, 
however, attended with infiltration, thickening, inflammatory 
symptoms, and itching. 

Eczema of the leg is frequently associated with varicose 
veins, this imperfect state of the circulation being one of 
the common causes of the disease. Ulcers resulting from 
the breaking down of these veins are often present, and 
complicate the condition ; they interfere, also, with the 
treatment. 

The diagnosis is rarely obscure. The hypertrophic state 
of the tissues known as elephantiasis Arabum is at times 
accompanied by eczema; the eczema, however, will be recog- 
nized as being secondary to the original trouble. If varicose 
ulcers happen to be present, they are to be distinguished 
from syphilitic ulcers, which often show themselves in this 
region. 

The treatment will depend upon the variety, stage, and 
extent of the disease, and the surroundings of the patient. 

In cases of moist eczema, unquestionably the most suc- 
cessful plan of treatment is that consisting in the employ- 
ment of sapo viridis and unguentum diachyli, already de- 
scribed. It is in these very cases that the most favorable 
results follow this treatment, provided it be properly car- 
ried out. Where the disease is not in a discharging state, 
other methods involving less time and trouble may be sub- 
stituted, and sometimes with equal success. The various 



ECZEMA. 213 

remedies referred to in considering the general treatment 
of eczema may also be prescribed, as may appear suitable 
to the case. 

It is very necessary where there are varicose veins, or 
where there is tendency to swelling, that the limb be prop- 
erly bandaged. The bandage should be applied both for the 
purpose of retaining the dressings in their place, and for 
supporting the leg and relieving the congestion. This sup- 
port will prove of great comfort to the patient, and will 
materially hasten the cure. Ulcers, when present, may 
receive the same management as the eczema, or they may 
demand special handling. 

Eczema Manuum. — Owing to the peculiar anatomical for- 
mation of the skin about the hands, as well as to the great 
exposure to which they are subjected, they are very fre- 
quently the seat of disease. One or both hands may suffer; 
ordinarily both are affected. The feet may be attacked at 
the same time, though this rarely occurs. The feet are not 
particularly liable to eczema. All of the varieties of eczema 
are encountered upon the hands ; erythema, vesicles, papules, 
and even pustules are here frequently seen in their typical 
form. Fissures, sometimes of great size and depth, are 
usual about the knuckles, and upon the backs and also the 
palms of the hands. They constitute a very troublesome and 
painful lesion, and at times are hard to manage, on account 
of the constant motion which is necessarily taking place. 
The hands are subject to attacks of acute as well as chronic 
eczema. All of the fingers are usually more or less involved, 
especially upon their lateral surfaces; in cases of vesicular 
eczema of the sides of the fingers, the entire epidermis is at 
times undermined by fluid, forming bulla?. 

In connection with chronic eczema of the fingers, the nails 
will also frequently be observed to be diseased. 

The causes of eczema of the hands are numerous, and 
embrace all those irritating substances with which the hands 
are apt to come in contact in certain occupations. Chemists, 
workers in alkalies or acids, bricklayers, bakers, grocers, 
cooks, and others, who have their hands continually exposed 
to the action of poisons, are liable to be attacked. Among 



214 EXUDATIONS. 

the various substances none act upon the skin so deleteriously 
as alkalies. 

As scabies always affects the fingers in preference, the 
diagnosis between eczema and this disease is very often ex- 
tremely difficult. The presence of the acari scabiei, as proved 
by the burrows, which are to be sought for on the lateral 
surfaces of the fingers, is at times necessary to determine the 
diagnosis. In eczema the vesicles are apt to be numerous, 
and crowded upon a given portion of the hand ; in scabies 
they are more scattered, and are found alike over all the 
fingers. The vesicles and pustules of eczema are quite 
small; in scabies they are of variable size, and often large. 
The vesicles of eczema rupture shortly after they form, espe- 
cially upon parts where the epidermis is thin ; in scabies 
they often remain whole until disturbed by scratching or 
other mechanical means. The vesicles of scabies commonly 
exhibit a fine, dark, irregular line, made up of points, through 
their tops, being the original burrow in the epidermis which 
has been raised by the formation of the vesicle. This is 
characteristic of the disease, and is of course wanting in 
simple eczema. The peculiar distribution of scabies over 
certain regions of the body will, with the above features, 
enable one to make the diagnosis with certainty. 

Vesicular eczema of the hands may be confounded with 
dysidrosis. 

Eczema of the hands and fingers is particularly intracta- 
ble. In the treatment, the cause is first of all and at once 
to be removed. The hands must be protected from all irri- 
tating influences; they should be kept out of water; the use 
of soap for washing purposes should be prohibited; exposure 
to heat should be avoided; gloves or other coverings should 
be worn, to guard them from the air; and, finally, every 
assistance to recovery should be afforded them. Each finger 
should receive proper attention ; the dressings should always 
be carefully applied. 

Eczema Palmarum et Plantarum. — Eczema presents the 
same features in both of these regions. Owing to the thick- 
ened state of the epidermis it gives rise to peculiar lesions, 
which' at times obscure the diagnosis. Great infiltration, 



ECZEMA. 215 

thickening, callosity, hardness, dryness, and Assuring, usually 
mark eczema of the palms and soles. It is always a chronic 
condition, and frequently lasts a long while. The fissures 
are often very deep and so painful that the patient is unable 
to use his hands, or, if upon the soles, to walk. One or 
both palms or soles may be affected, either alone or in con- 
nection with other parts. At times palms and soles are 
simultaneously attacked. 

The diagnosis is, as a rule, attended with difficulty, inas- 
much as both psoriasis and syphilis are frequently localized 
upon these regions, and often bear a close resemblance to 
eczema. Eczema differs from psoriasis in the following 
points. The fissures of eczema are apt to be moist and 
bloody; in psoriasis they are dry, and show but little tend- 
ency to bleed. The patches of eczema are generally larger 
and more diffused than those of psoriasis. In psoriasis 
patches, the edges always terminate abruptly; in eczema 
they pass gradually into the healthy skin. The color of 
psoriasis is usually of a deeper hue than that of eczema. 
The scales, moreover, of psoriasis are whitish in tint, while 
in eczema they are yellowish. The scales of psoriasis are 
also larger and thicker than those of eczema. 

The itching is always more marked in eczema than in 
psoriasis. The presence of either disease on other parts of 
the body will be sufficient to clear away doubt. 

Syphilitic manifestations occasionally show themselves on 
the palms and soles, and must be distinguished from eczema. 
The infiltration of syphilis is of a firmer nature than that of 
eczema; it also extends deeper into the tissues, and gives 
the sensation of there being a compact deposit in the skin. 
Eczema is usually much more uniformly diffused than syph- 
ilis; the patches of syphilis are apt to be smaller, and more 
circumscribed, and to have a tendency to spread on the 
periphery. Syphilis, as a rule, does not itch; eczema always 
does. In syphilis the line of demarcation between disease 
and health is always sharply drawn. The history may be of 
some assistance in determining the nature of the lesion. 

Eczema Unguium. — Eczema not unusually assails the nails. 
One, two, or all may be affected. They, however, are not 



216 EXUDATIONS. 

often involved alone, but commonly in connection with the 
lingers. The disease is characterized by roughness, want of 
polish, unevenness, and a punctate or honey-comb appear- 
ance, which latter sign, however, belongs also to psoriasis. 
The nail becomes depressed, particularly at its root, at which 
point its proper nutrition appears to be arrested. The free 
edges are often thin, ragged, and broken. The nail may 
remain in its diseased condition until it by degrees recovers 
its health, or it may be cast off and regenerated. 

Local treatment is to be directed to the root rather than 
to the nail itself. 

HERPES FEBRILIS. 

Syn. Hydroa Febrilis ; Fever Blister. 

Herpes febrilis is an acute, inflammatory affection, con- 
sisting of one or of several grouped vesicles, occurring for 
the most part about the face and genitalia. 

Symptoms. — It is an acute disorder, seldom having a dura- 
tion of more than a few days. The eruption is often pre- 
ceded and attended by symptoms of general malaise and 
slight pyrexia. This variety of herpes may occur either 
alone or in the course of a number of serious febrile dis- 
eases, as pneumonia, pleurisy, and the various fevers. The 
vesicles appear in the form of a cluster; they are always few 
in number, rarely showing more than three or four distinct 
lesions. They are pin-head to split pea sized, and contain a 
clear watery fluid, which soon becomes somewhat thick, and 
desiccates in small brownish crusts. If rubbed or picked, 
an excoriation takes place, which cicatrizes without leaving 
a permanent scar. The appearance of the vesicles is pre- 
ceded by a feeling of heat and distress in the region, together 
with marked swelling and redness. These symptoms decline 
with the advent of the eruption. The affection is very apt 
to recur from time to time in the same individual. 

There are two distinct regions in which febrile herpes 
generally shows itself, from which circumstance the names 
herpes facialis and herpes progenitalis have arisen. 

Herpes Facialis. — This may occur upon any part of the 
face, although it is commonly encountered about the lips, 



HERPES FEBRILIS. . 217 

and especially the red of the lips; hence the name herpes 
labialis. It is frequently seen upon the alse of the nose; 
more rarely it is observed upon other regions of the face, 
and the auricles. The mucous membrane of the mouth, 
and the tongue, are also not infrequently the seat of this 
form of herpes. Here the vesicles rupture early, through 
maceration, and therefore are seldom observed as vesicles, 
but rather in the form of patches, and shreds of epithelium. 
Upon the lips the vesicles are usually small, few in number, 
and confined to one cluster. The upper lip is more com- 
monly affected, although the lower one is likewise often 
involved. The vesicles may either remain single or may 
coalesce, forming a vesicular patch, which terminates in a 
brownish crust. No ulceration takes place, and conse- 
quently no scars result. Herpes facialis is usually caused 
by some febrile disturbance of the system. It is seen in 
connection with slight fevers and colds, and also attending 
more serious affections, as intermittent and typhoid fevers, 
and other disorders. 

Herpes Progenitalis. — Upon the male this is observed 
chiefly about the prepuce, which occurrence has given rise to 
the term herpes pr^eputialis. It may also occur upon the 
glans and upon the dorsum. In the female it shows itself 
upon the labia or upon the mons veneris. The attack is 
usually preceded by a feeling of uneasiness or slight burning 
in the part, followed by a small group of vesicles ; their 
appearance is generally quite sudden. As a rule, only one 
cluster is seen. The smarting and burning sensations are at 
times marked, and occasion annoyance. The parts are apt 
to be red and swollen. The vesicles frequently run together 
and form small patches, which become covered with a crust. 
Upon the inside of the prepuce and upon the inner surface 
of the labia, the vesicles commonly break down and result 
in excoriations, which resemble superficial ulcers covered 
with a whitish deposit. Occurring here, the affection is 
liable to be mistaken for one form or another of venereal 
disease. The lesions are occasionally very much like those 
of chancroid, and great care is in these cases necessary in 
order to make the correct diagnosis. The course of herpes, 



218 EXUDATIONS. 

however, always enables the observer to come to a definite 
conclusion upon this point. A few days suffice to deter- 
mine the question, for in this time herpes will have disap- 
peared spontaneously, whereas a venereal ulcer will have 
increased in size. Where there is doubt, three or four days 
should be allowed to pass before pronouncing positively 
upon the nature of the trouble. Herpes progenitalis is 
exceedingly prone to recur repeatedly throughout life. 

Treatment. — No active treatment is called for. The lesions 
should always be guarded from rupture and laceration. A 
simple cerate or ointment may be used to protect the vesi- 
cles from excoriation. Camphor cerate with glycerine will 
be found an agreeable application. A lotion consisting of 
equal parts of glycerine and orange flower water also makes 
a grateful preparation. 

Where attacks frequently recur, the general condition 
should be inquired into. The bowels should be carefully 
regulated. 

Herpes G-estationis. — Under this name Milton* and Bulk- 
leyf have described a rare affection of the skin, peculiar to 
pregnancy, and which they regard as a variety of herpes. 
It consists in the development of erythema, papules, vesicles, 
and bullae. The vesicles predominate. They are attended 
with intense itching and burning sensations. The lesions 
are commonly grouped, but do not follow any nerve-tracts. 
The vesicles and bullae vary in size; they may be pea sized 
or as large as a w T alnut. They usually first appear on the 
extremities, and afterwards involve other portions of the 
body. It is an affection directly dependent upon the gravid 
state of the uterus. It may appear at any period of gesta- 
tion up to the seventh month, and when present usually con- 

* The Pathology and Treatment of Diseases of the Skin, p. 205. London, 
1872. 

f American Journal of Obstetrics and Diseases of Women and Children. 
Feb. 1874. 

Wilson was the first to mention the disease. He speaks of it as " herpes 
circinatus bullosus." (Diseases of the Skin, p. 294. London, 1867.) Hardy, 
under the name of "pemphigus prurigineux," also mentions the affection 
(Lecons sur les Maladies de la Peau, p. 137. Paris, 1863). 



HERPES FEBRILIS. 219 

tin ues until after delivery. It does not terminate in its course 
immediately after delivery, but slowly retrogrades by the 
development of fewer and fewer vesicles; it is apt to recur 
with succeeding pregnancies. It is at times accompanied 
by urticaria, neuralgia, and other neurotic troubles. Under 
the name of herpes impetigikeformis — so named on account 
of the impetiginous appearance of the crusts — Hebra* has 
described a similar, although different, form of eruption, 
occurring in the course of pregnancy, of which he had seen 
five examples. The lesions consisted of grouped vesicles, 
situated upon inflamed bases, which in all the cases ob- 
served began about the genitalia, subsequently diffusing 
themselves, by successive crops, over the body. The dis- 
ease was attended with great prostration, rigors, and in- 
tense fever, and in four cases out of the five terminated 
fatally. 

Neumann, in the last edition (1873, p. 188) of his work 
upon diseases of the skin, describes an affection which he 
considers a variety of herpes, of which he had encountered 
five examples. It began with the formation of small pale- 
red papules, which in the course of a few days increased 
peripherally, their centres becoming bluish-white and vesic- 
ular. As these papular patches spread, new vesicles formed 
on their margins, while those in the centre dried up. The 
vesicles were pin-head in size, and were but very slightly 
raised above the level of the skin. The patches were of 
the size of coins, were more or less circular, and were in- 
clined to coalesce, forming gyrate forms. The course of the 
disease was slow, lasting months, and by degrees invaded 
large portions of the body. It was attended with violent 
itching. On the palms and soles it resembled vesicular 
eczema. On some parts of the body thick and adherent 
crusts formed. f 

* Wiener Med. Wochenschrift, No. 48, 1872. Abstract to be found in the 
Lancet, March 23, 1872. 

f Since writing the above, Neumann has described this disease more in 
detail, under the name of Dermatitis circumscripta herpetiformis. Yiertel- 
jahresschrift fur Derm, und Syph., erstes Heft, p. 41, 1875. 



220 EXUDATIONS. 



HERPES ZOSTER. 

Syn. Zona; Cingulum ; Ignis Sacer ; Zoster; Shingles; Germ., G'urtel- 
krankheit; Feuerglirtel ; Fr., Zona. 

Herpes zoster is an acute, inflammatory disease, charac- 
terized BY DISTINCT GROUPS OF WELL-FORMED VESICLES SITUATED 
UPON INFLAMED BASES, ACCOMPANIED BY NEURALGIC PAIN. 

It is an acute disease, lasting usually from ten days to 
three weeks from its commencement to its termination, and 
is accompanied by well-marked symptoms. The disease 
commences by neuralgic pains, which are experienced for 
several days before any sign of eruption shows itself. These 
pains are usually of a severe nature, and involve both the 
deeper and the more superficial structures of the region in 
a manner altogether disproportionate to the amount of erup- 
tion which follows. An inflamed condition of the skin is 
now observed, attended with heat and burning sensations, 
and groups of vesicles appear over the region. They are 
of the size of pin-heads and split peas, usually separate one 
from the other, and are situated on a red surface. They 
may be so crowded together as to coalesce, when they form 
irregular patches. The vesicles continue to appear rapidly, 
one group after another, until the fourth or fifth day, when 
the eruption is at its height ; it stands in this condition for 
a few days, when it is seen to decrease, the vesicles drying 
up, until, at the end of ten days or longer, nothing remains 
but dry, brownish crusts, which soon drop off, leaving scars 
in the skin, more or less pronounced according to the severity 
of the attack. The vesicles do not burst as in eczema, but 
remain tense throughout their course. They contain a clear 
yellowish fluid, which, as the disease declines, gradually turns 
into a thicker fluid, ultimately becoming puriform. When 
at its height the eruption is very perfect in its anatomical 
characters, the vesicles being well shaped, fully distended, 
with translucent, yellowish contents, and seated upon a bright 
inflammatory patch of skin. They always tend to group, and 
are usually closely crowded together; where the disease is 
extensive, a number of separate groups may be observed. 

Herpes zoster may also run an abnormal course, the above 



HERPES ZOSTER. 221 

symptoms being only in part present. The vesicles may not 
be characteristic, appearing rather as aborted vesicles ; on 
the other hand, small bullae and pustules may occasionally 
show themselves. There are also certain cases in which 
the whole process is checked in its course just as the symp- 
toms upon the skin are about appearing. 

The neuralgic pain may vary exceedingly in intensity ; 
it is slight at times, and in other cases of an excruciating 
nature. The amount of eruption in zoster is never in any 
manner proportionate to the amount of pain. 

The disease attacks various regions of the body, but has 
marked preference for certain parts. It is in all cases found 
upon nerve-tracts, and is almost invariably confined to one 
side of the body. According to the region upon which the 
disease shows itself, it is termed zoster capitis, z. faciei, 

Z. NUCM!, Z. BRACHIALIS, Z. PECTORALIS, Z. ABDOMIXALIS, Z. 

femoralis. To express the precise locality invaded, other 
terms indicative of the anatomical region are also employed, 
as, for example, cervico-brachialis, dorso-pectoralis, etc. 

About the head, it is encountered both on the scalp and on 
the forehead. The eruption usually makes its appearance on 
the course of the supra-orbital nerve, passing upwards over 
the scalp. The eye is apt to become involved, and the pain 
to be excessive. There is frequently injection of the con- 
junctiva, followed by general and profound disturbance of 
the organ. The disease may also start at the back of the 
head, spreading forward and occupying the whole side. The 
face alone, especially the cheek, may also be the seat of the 
disease. Likewise the side of the neck, on a line with 
the second and third cervical vertebrae, extending forwards 
towards the larynx. 

In zoster brachialis the eruption usually first makes its 
appearance in the region of the lower cervical vertebrae, 
passing over to and down the arm to the elbow, or even 
farther. The flexor surface is commonly attacked. This 
is quite a frequent seat of the disease. 

The chest is another region often involved, the vesicles 
forming parallel with the ribs. The intercostal nerves here 
determine the track of the eruption. Zoster in this locality 



222 EXUDATIONS. 

generally gives rise to great pain and difficulty in breathing; 
in its early stage the distress may be mistaken for incipient 
pleurisy. The abdominal region, supplied by the lower 
dorsal and lumbar nerves, is very similarly affected. The 
two last named regions are the most common local varieties 
of zoster, and have occasioned the name by which the disease 
is known. 

Zoster also occurs on both the anterior and the posterior 
surface of the thigh ; the buttock is quite a frequent seat 
It rarely occurs below the knee. It is also met with about 
the genitalia. 

The course of herpes zoster is always an acute one, termi- 
nating in recovery. The process is not infrequently attended 
by a certain amount of ulceration, and subsequent cicatrices, 
which may remain for life. The affection rarely occurs 
twice in the same individual. It is not contagious. Neu- 
ralgic pains are not infrequently present about the seat of 
the eruption long after all traces of the vesicles have dis- 
appeared. The disease is met with in both sexes, and in 
children as well as in adults; it is seen in the very young 
and also in the aged. 

Etiology. — The causes which occasion the disease are in- 
volved in obscurity, although clinical experience teaches that 
their nature may be quite different. It is, however, well 
recognized that in all cases the eruption is dependent upon 
a peculiarly irritable state of the cutaneous nerve trunks and 
branches. The cause producing this condition may be found 
in various influences. Atmospheric changes, especially sud- 
den cold, are known to call forth attacks of zoster. Exposure 
to damp winds or wet weather, and the checking of profuse 
perspiration, have been observed to act as causes. Mechan- 
ical violence to a part, and unusual exertion, have also been 
noted to give rise to the eruption. Barensprung* was one 
of the first who considered the cause to be in the nerves, 
and that the inflammation was conducted through them to 
the skin. He was further of the opinion that the disease was 



* Die Giirtelkrankheit, Charite-Annalen, ix. p. 114. Berlin. This paper 
is a most valuable contribution to the subject. 



HERPES ZOSTER. 223 

to be looked upon as belonging to that class of affections 
which are influenced by the weather. 

Pathology. — The writer just mentioned was also the first to 
present the view that the disease was one of the ganglionic 
system. He determined the primary seat of the affection to 
be in the spinal ganglia. In cases of zoster of the trunk he 
found the intercostal nerves thickened and injected, with 
their spinal ganglia softened and altered in structure, the 
inflammation always extending from the ganglia to the per- 
iphery. Danielssen* also demonstrated a marked reddened 
and swollen condition of an intercostal nerve, accompanied 
by an infiltration of the neurilemma. Weidnerf records 
changes not unlike those observed by Barensprung. 

WyssJ gives a very accurate and valuable description of 
the changes encountered in a case which died in the early 
stage of zoster involving the eye and forehead. The first 
branch of the trifacial nerve was seen to be broader, thicker, 
and softer than that of the opposite side of the body, and had 
a reddish-gray color. The individual nerve bundles were 
separated by a reddish-gray, soft tissue containing numerous 
vessels. The nerve was surrounded by an extravasation of 
blood, along its course from the orbit to the ganglion 
Gasseri, this body being considerably larger and softer than 
normal. It was, moreover, not yellowish-white, but bright 
red in color. The nerve was healthy at its origin from the 
brain, but was seen to become diseased as it entered the 
ganglion, and to contain numerous small blood extravasa- 
tions. The microscopic examination of the skin showed 
the papillae and corium to be largely infiltrated with cells. 
The rete was intact in some places, but entirely destroyed at 
other points. These facts corroborate the original opinion 
of Barensprung, that the disease consists in an inflammation 
of the spinal ganglia carried forward along the nerves to 
their termination upon the skin. 



* Barensprung, loc. cit., p. 119. 

f Berliner Klin. Wochenschrift, No. 7, 1870. Archiv fur Derm, und Syph., 
4 Heft, 1870. 

% Archiv der Heilkunde, iv. u. v., 1871. Archiv fur Derm, und Syph., 3 
Heft, 1872. 



2:24 « EXUDATIONS. 

Biesiadecki,* and Haightf of New York, have both demon- 
strated that the vesicles are formed in the same manner as 
in eczema. Biesiadecki found the papillae considerably in- 
creased in size and tilled .with new cells, which penetrated 
into the corium and even into the subcutaneous tissue. The 
bloodvessels of the papillse were enlarged and distended with 
blood. Numerous spindle-shaped cells were seen to come 
out of the papillae and to force themselves into the mucous 
layer, separating themselves freely, so that the epithelial 
cells were compressed and made to assume the form of 
narrow perpendicular bands. This network, therefore, con- 
sists of the isolated and compressed cells of the middle and 
upper layers of the rete Malpighii, together with cells from 
the ducts of the sweat glands and hair follicles. These 
views correspond with those of Auspitz and BaschJ and 
Ebstein.§ The network referred to, according to Biesiadecki, 
is tilled with connective-tissue cells which have made their 
way up through the mucous layer. Haight found numbers 
of round, nucleated cells in and around the neurilemma; 
they were probably pus cells. He also discovered the nerves 
to be swollen, the medullary substance softened, and the axis 
cylinder eccentrically increased in size. 

Diagnosis. — The characters of herpes zoster are usually so 
well marked that no trouble should arise in the diagnosis. 
The premonitory symptoms of neuralgic pain in the part 
about to be the seat of the eruption must always point 
strongly to this affection. The appearance of the vesicles, 
in distinct groups, upon a highly inflammatory base, and the 
tendency to preserve their form intact, are characteristic. 
The vesicles are larger than those of eczema, varying in 
size from a pin-head to a split pea. The vesicles of eczema 
always rupture, and ooze forth a fluid which rapidly forms 
crusts; there is no discharge in zoster. The subjective 
symptoms of zoster are decided pain, smarting, and heat; in 
eczema there is always positive itching. 

* Beitrage zur Phys. und Path. Anat. der Haut, p. 245. Wien, 1867. 
f Sitzungsberichte der Kais. Akademie. Wien, 1868. 
X Virchow's Archiv, Bd. xxviii. p. 337. 
§ Virchow's Archiv, Bd. xxxiv. p. 598. 



HEKPES ZOSTER. 225 

Erysipelas should never be confounded with herpes zoster. 
The line of demarcation about erysipelas, the deep reddish 
color of the inflammation, the constitutional symptoms, to- 
gether with the absence of grouped vesicles and of neuralgic 
pain, serve to distinguish it from zoster. 

Herpes zoster is to be diagnosed from the simple febrile 
form of herpes seen about the face and genitalia, chiefly by 
the presence of pain, and the tendency it has to occur once 
only in a lifetime. Febrile herpes inclines to repeated at- 
tacks in the same individual. It also confines itself to cer- 
tain regions, as the lips, nose, and genitalia ; herpes zoster 
is not commonly encountered in these localities. In febrile 
herpes there is usually only one group of vesicles; in zoster 
several distinct groups ordinarily occur. Zoster is almost 
invariably unilateral; herpes febrilis often shows itself on 
both sides or in the median line itself. 

Treatment. — It will be borne in mind that the affection 
runs an acute course, terminating in spontaneous recovery; 
also, that the course is usually a benign one as regards the 
result, except in those cases where sensitive regions of the 
body, as the e} 7 e, are involved. 

Internal medication has not heretofore proved of much 
avail in influencing the course of the eruption, although, 
according to Ashburton Thompson* and Bulkley,f we have 
a valuable remedy in the phosphide of zinc, which has 
recently been recommended by the former of these gentle- 
men in doses of one-third of a grain, to be given at the com- 
mencement of an attack and to be repeated every three 
hours. It is said to control the pain and to abort the erup- 
tion in a remarkable manner. My own experience with the 
remedy in these cases is as yet too limited to warrant the 
expression of an opinion. 

General symptoms, however, may be combated as they 
present themselves. Saline laxatives or effervescing draughts 
may often be agreeable to the patient in the first stage of 
severe zoster. Opiates, in particular morphia, in the dose 

* G-lasgow Medical Journal, October, 1874. 
f Archives of Dermatology, January, 1876, p. 158. 
15 



226 EXUDATIONS. 

of a quarter grain or less, to suit the age and habit of the 
individual, given at night, are useful towards the third or 
fourth day, when the pain is usually so great as to prevent 
sleep. In violent andextensive cases a course of tonic treat- 
ment, consisting either of iron, arsenic, the mineral acids, 
or quinine, may be beneficially prescribed, for the purpose 
of restoring the health, which not infrequently has become 
considerably impaired. 

External treatment is of importance and value. The parts 
should be protected from the irritation of the clothes and 
from other external influences ; the vesicles should not be 
punctured, but preserved as far as possible intact. Various 
dusting powders, containing camphor and morphia, may be 
advantageously employed. These should be freely sprinkled 
over the part and covered with a bandage. Anodyne oint- 
ments may also be used ; those containing powdered opium, 
a drachm to the ounce, will be found of greatest service. 
Anodyne lotions containing opium and camphor are also to 
be recommended. Carbolic acid, in the form of a lotion, ten 
grains to the ounce of water, may be employed with advan- 
tage in certain cases. A preparation of value is found in 
flexible collodion with morphia, in the strength of ten grains 
to the ounce; to be painted over the eruption several times 
in the course of the day. Great relief is often experienced 
from this procedure. The subcutaneous injection of the sul- 
phate of morphia is another desirable method of relieving the 
pain, from three to six minims of Magendie's solution (gr. 
xvi, ad fSi) being used for each injection; it should be given 
at night. One of the most successful plans, however, of 
treating zoster is by means of the galvanic current. This 
has been recently brought to the notice of the profession 
by several experimenters, and offers a prompt and effectual 
means of relief. The constant current will be found of most 
service, and is to be applied directly to the seat of the erup- 
tion and over the course of the nerves by sponge electrodes. 
I have found from fi.ve to ten cells to be sufficient in the 
majority of cases, the application being continued for from 
fifteen to thirty minutes at each sitting, and repeated every 
day, or even twice a day, until recovery takes place. Central 



HBEPES IRIS. 227 

galvanization is also recommended. There is no doubt 
that both the pain and the eruption may be arrested by the 
timely use of the current, and even after the disease is at 
its height, great ease may be experienced from its applica- 
tion. The after-pains of zoster are also successfully treated 
by the galvanic current. 

Prognosis. — A few weeks usually suffice for the sponta- 
neous cure of zoster, although severe cases may linger a 
month or longer before disappearing. Occurring about the 
head, the pain is always intensely neuralgic and violent. 
Zoster of the orbital region may seriously involve the eye. 
Apart from this, no bad results follow the disease, excepting 
scars, which are at times quite unsightly. 

HERPES IRIS. 

Syn. Hydroa ; Herpes Circinatus ; Germ., Herpes Iris ; Fr., Hydroa Vesi- 
culeux. 

Herpes iris is an acute, exudative disease, characterized 
by one or more groups of variously-sized vesicles arranged 
in the form of concentric rings, attended by the display of 
peculiarly varied colors. 

Symptoms. — The patches vary in size from a small coin to 
several inches in diameter, and are made up of a number of 
distinct vesicles, which arrange themselves side by side so as 
to form a complete and often perfect ring. Two, three, or 
more of these rings exist as a series, extending outwards 
towards the periphery of the patch. In size the vesicles vary 
from a pin-head to a split pea, or larger; they may be discrete 
or confluent, more often the latter. In number the patches 
also vary ; several or a dozen may be present. Between 
the vesicles the skin is pinkish or reddish and somewhat 
raised above the surrounding skin. The vesicles contain a 
yellowish watery fluid, which, after a day or two, dries, 
forming a slight brownish crust. The oldest vesicles, those 
in the centre, desiccate first, even while new ones on the 
periphery are being produced. 

The affection first shows itself as one or more papules 
around a central point; these rapidly change into vesicles, 
which assume the shape of a circle. No sooner has one ring 



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HEEPES IRIS. 229 



known concerning the nature of this curious affection. 
There is, however, sufficient clinical proof to demonstrate 
that, although quite formidable in its appearance, it is in 
reality a simple disorder. The causes are as yet unrecog- 
nized. 

Pathology. — The disease undoubtedly bears the closest 
relationship to erythema multiforme. It is indeed to be 
viewed as but an advanced stage or a modification of this 
disorder. From the several opportunities which I have had 
of observing the course of the complaint, it seems to me 
clear that they are one and the same process, only termi- 
nating in a different manner: in one individual, in an ery- 
thema; in another, differently constituted, passing on to 
vesiculation.* 

The objective symptoms, however, are so peculiar and of 
so different a character from erythema multiforme, as to 
warrant placing the affection among the forms of herpes 
rather than with the erythemata, particularly as the lesions 
are of a markedly herpetic nature. It is a simple, benign, 
exudative process of a mild type. 

Diagnosis. — The presence of the vesicles serves to distin- 
guish it from erythema multiforme. From herpes zoster it 
may be known by the absence of all neuralgic pain and of 
burning. The distribution and arrangement of the vesicles 
are, moreover, altogether different. In herpes iris they are 
arranged in rings, one outside the other; in zoster they are 
clustered or grouped irregularly. The regions attacked are, 
moreover, not the same; the hands and feet are rarely if ever 
the seat of zoster. 

The affection is most liable to be mistaken for pemphigus. 
But the lesions are unlike those of pemphigus in their size, 
formation, and course, and in their arrangement. The pecu- 
liar coloring of a patch of herpes iris is also always sufficient 
to distinguish it from pemphigus. The diseases cannot be 
confounded if their general features are borne in mind. 
The arrangement of the vesicles, and the absence of marked 
itching, are sufficient to separate herpes iris from eczema. 

* See Erythema Multiforme, p. 143. 



230 EXUDATIONS. 

Treatment. — No method of treatment has any effect in 
changing or arresting the course of the disease. . Its dura- 
tion varies from a few days to several weeks, when it ter- 
minates in recovery. If any medicines be given, they should 
be of a simple nature, as may seem indicated in the case. 
Saline laxatives may be ordered, especially where there is a 
tendency to constipation. Locally, the part should be pro- 
tected from the clothing; the vesicles kept intact, and dusted 
from time to time with a powder of oxide of zinc. If exco- 
riations exist, the oxide of zinc ointment may be applied 
upon a cloth and bound to the limb with a bandage. 

Prognosis. — This is always favorable. The patient may be 
assured that the eruption will disappear in the course of a 
few weeks. Pigment stains may be left, but these are soon 
reabsorbed. No unpleasant symptoms remain. 

MILIARIA. 

Syn. Miliaria Kubra ; Miliaria Alba; Sudamina (Hebra) j Lichen Tropi- 
cus ; Prickly Heat. 

Miliaria is an acute, inflammatory disorder of the sweat 
glands, characterized by numerous pin-point and millet-seed 
sized papules or vesicles, attended by pricking, tingling, and 
burning sensations.* 

Symptoms. — Miliaria may show itself either as a papular or 
as a vesicular eruption; in many cases both papules and 
vesicles are present, although usually one or the other form 
of lesion will predominate. The two varieties call for sepa- 
rate description. 

Miliaria Papulosa. — This variety, known as lichen 
tropicus or prickly heat, commonly commences with the 
formation of numerous minute, acuminated, bright red 
papules. The lesions are exceedingly small, pin-head and 
millet-seed in size, and very slightly raised above the level 
of the skin. They occur in great numbers; are discrete, 

* Miliaria does not include the disease known under the names of Miliary 
Fever, Miliary Eruption, etc., a complete account of which may be found in 
Ziemssen's Cyclopaedia of the Practice of Medicine, vol. ii. New York, 
1875. 



MILIARIA. 231 

although often crowded together; and are usually dispersed, 
without order in their arrangement or distribution, over a 
considerable surface. They make their appearance sud- 
denly, and are preceded by and accompanied with more or 
less sweating. Vesico-papules and vesicles are usually seen 
here and there between the papules, rendering the affection 
somewhat multiform as regards its lesions. 

Miliaria Vesiculosa. — In the place of papules, vesicles 
may form. They are very small, seldom being larger than 
pin-points and pin-heads. They are usually acuminated in 
shape, rising from the surface in the form of whitish or yel- 
lowish minute points. They are generally present in large 
numbers, thousands of them appearing upon one patch, as, 
for example, upon the abdomen ; they are always discrete. 
The skin from which the vesicles arise is always more or 
less inflamed; commonly it is of a bright red color, owing 
to each vesicle being surrounded by an areola (miliaria 
rubra). The vesicles themselves, when recent, are trans- 
parent and contain a fluid the color of water; when older 
they are opaque and yellowish (miliaria alba). Owing to 
the multitude of the vesicles and their proximity to one 
another, they are apt to give the skin a yellowish cast. 

In addition to the presence of the vesicles, there is always 
more or less general sweating. The eruption may show 
itself in patches here and there, or it may appear over the 
greater portion of the body. Its usual seat is the trunk, but 
it may also attack the face, arms, and lower extremities. It 
is commonly seen about the abdomen, the sides of the 
trunk, and the back. 

The vesicles run an acute course, drying up in a day or 
two, and terminating in slight desquamation. They do not 
tend to rupture spontaneously. If scratched or rubbed, how- 
ever, they break down and discharge their contents, which 
form into extremely small, yellowish crusts. Inasmuch as 
the fluid which they contain is never more than the minutest 
drop, the crusting is in all cases insignificant. The affection 
may either come to an end in a few days or it may continue, 
new crops of vesicles appearing from time to time. Its dura- 
tion will depend upon the nature of the cause. I have seen 



232 EXUDATIONS. 

cases which lasted throughout the entire summer, and even 
far into the autumn. 

Miliaria may attack all parts of the body, but certain 
regions, as the abdomen, chest, neck, and arms, are com- 
monly invaded. The disorder makes its appearance very 
suddenly, without premonitory symptoms, and quickly as- 
sumes its definite characters; a few hours usually suffice for 
its development. The process varies in intensity; at times 
it is slight, in other cases it is so severe as to be the source 
of very great annoyance. It is apt to disappear and to re- 
appear unexpectedly, often without apparent cause. The 
taking of food or of hot drinks is frequently a sufficient 
cause to aggravate it, or even to produce an outbreak, when 
there is a disposition to its manifestation. 

Both varieties of miliaria are attended by tingling, prick- 
ing, burning sensations, which are at times very distressing 
to the patient. 

Etiology. — It is caused by excessive heat. This may be pro- 
duced as the result of injudicious and superfluous clothing, 
or in consequence of a high external temperature. It is 
very frequently encountered during the summer months 
in various climates, especially upon the sudden advent of 
unusually warm weather. 

The papular variety is very common in the tropics, — hence 
the name lichen tropicus, — where it is a much more highly 
developed and serious disorder than with us. It is usually met 
with in fleshy persons, who perspire profusely, and in children. 
Boys who exercise freely during the hot weather are very 
apt to be troubled with it. Those who have had it once are 
liable to suffer repeated attacks. Too much clothing, flannel 
or other irritating wear, tightly-fitting under-garments, and 
bandages, are all well-known exciting causes. 

The vesicular variety, on the other hand, according to my 
experience, inclines to manifest itself in weak and debilitated 
subjects rather than in the strong or stout. It is not rare 
to meet with it in poorly-nourished, feeble, puny infants 
and young children, especially in summer, although it is 
also seen upon these at other times of the year. The 



MILIARIA. 233 

superfluous under-clothing with which weakly infants are 
so often burdened is the cause of much miliaria. In adults 
I have also observed it in those who were suffering from 
ill health, nervous prostration, severe dyspepsia, and general 
debility. 

Pathology. — The pathology of the two varieties of miliaria 
is the same, — they are both inflammatory disorders of the 
sweat glands. . In one variety the process inclines to the 
formation of papules, which have their seat about the orifices 
of the excretory ducts; while in the other variety the dispo- 
sition is to vesiculation. The line separating these lesions, 
however, is in many instances but ill defined, and in conse- 
quence there results a mixture of papules and vesicles. The 
process, viewed in its totality, inclines to vesiculation. It 
may be very aptly compared to that which frequently takes 
place in eczema, where papules and vesicles are produced 
side by side. Differences in individuals, I think, account for 
the manifestation of one or the other lesion. Papular mili- 
aria is to vesicular miliaria what papular acne is to pustular 
acne; they are merely varieties or, in some cases, stages of 
the same process. Congestion, followed by slight exudation, 
takes place about the ducts with very great rapidity, and, in 
a short time, gives rise to the minute papules or vesicles, as 
the case may be, which remain until the cause producing 
them has been modified, when they quickly undergo absorp- 
tion. There can be no doubt that the cutaneous nerves are 
extensively involved in the process, as shown by the pecu- 
liar subjective symptoms ; whether this derangement of the 
nerves be primary or secondary it is impossible to determine. 

Diagnosis. — No difficulty should arise in recognizing milia- 
ria, when the nature and seat of the affection are taken into 
consideration. 

The papular variety possesses such peculiar symptoms, and 
is, moreover, a form of disease so common and well known, 
that it can scarcely be confounded with other affections. It 
is produced alone by unusual and sudden heat, and conse- 
quently is to be looked for only during warm weather. It 
may be diagnosed from eczema papillosum, the disease for 
which it is most likely to be mistaken, by its history, course, 



284 EXUDATIONS. 

and striking subjective symptoms. It always makes its ap- 
pearance suddenly, often in an hour's time; eczema, on the 
other hand, manifests itself, in comparison, slowly. It may 
continue several hours or days, disappearing usually in as 
rapid a manner as it came. Removal of the exciting cause — 
heat — tends immediately to relieve the condition, and very 
often to dispel the affection completely. Eczema is not 
influenced in this manner by any treatment; it is more per- 
sistent, the exudation being of a different character. The 
papules of eczema are larger, more elevated, and firmer than 
those of miliaria. 

The vesicular variety is to be diagnosed from sudamina 
by the presence of inflammatory signs.* The same kind of 
difference exists between sudamina and vesicular miliaria as 
between comedo and acne. The presence or absence of 
inflammation gives one or the other disease. Sudamina and 
miliaria, it will be understood, are separated from each other 
upon purely anatomical grounds, as, for example, is done 
in the case of erythema iris and herpes iris, and in other 
diseases. It is not to be confounded with vesicular eczema, 
to which it frequently bears a close resemblance in appear- 
ance. The history of the disorder, its sudden advent, the 
accompanying state of general perspiration, together with 
the peculiar pricking and burning sensations, will usually 
be sufficient to distinguish it. In miliaria each vesicle is 
observed, when sufficiently isolated, to be surrounded by an 
areola ; in eczema the whole surface is more or less uniformly 
inflamed. The local disturbance is always much greater in 
eczema than in miliaria. Miliaria is apt to come and go 
from day to day, in the form of repeated acute attacks; 
eczema usually runs a progressive and definite course. 
Finally, the vesicles of miliaria do not rupture sponta- 
neously; those of eczema always do. I consider this a 
characteristic feature, one which clearly separates the two 
diseases. The vesicles of miliaria may be, and often are, 
broken by the friction of the clothes, or by rubbing and 
scratching; the quantity of fluid poured out is exceedingly 

* See Sudamina, page 132. 



MILIARIA. 235 

minute, and never continues to exude as in eczema. Where 
eczema, however, supervenes upon vesicular miliaria the 
case at once is altered; in this event, we have all of the 
symptoms common to vesicular eczema, and the affection is 
no longer to be regarded as a miliaria. 

The eruption of scarlatina is at times complicated by the 
appearance of vesicular miliaria, producing an erythematous, 
minute vesicular and pustular affection. The diagnosis here 
is apt to be difficult, especially so if the constitutional 
symptoms of scarlatina be slight. 

Treatment. — The management of miliaria is usually simple. 
Active measures tend to increase rather than to improve the 
condition. Irritating washes and all ointments should be 
scrupulously avoided, for their employment favors the devel- 
opment of artificial eczema. The expectant treatment is 
the best. All precautions for the relief of the sweating are 
to be instituted. With lower temperature the glands cease 
secreting excessively; whereupon the condition, in the ma- 
jority of cases, tends to subside spontaneously. 

In rebellious cases the use of refrigerant diuretics, as the 
citrate or acetate of potassium in half-drachm doses, well 
diluted, will be found of decided value. Quinine is also a 
valuable remedy. In the case of the papular variety, the 
removal of the cause, a cool apartment, absolute rest, light 
clothing, plain food, acidulated drinks, and saline laxatives 
will ordinarily insure speedy relief. In the vesicular variety, 
where new crops of the vesicles are continually appearing, 
constitutional remedies may be prescribed to meet the re- 
quirements of the case. 

The local treatment is of very decided value. Absorbent 
dusting powders, consisting of lycopodium dust, or of equal 
parts of oxide of zinc and starch, will be found most useful ; 
they should be applied freely and frequently. Mild astrin- 
gent lotions may be employed in obstinate cases ; lotio nigra, 
sopped upon the parts from time to time through the day, 
will be of service. Alkaline baths or lotions may also be used 
with benefit. The patient should be warned against rub- 
bing or scratching the skin, for if this be indulged in the dis- 
order becomes at once greatly aggravated. Under judicious 



236 EXUDATIONS. 

treatment the complaint usually disappears in a short time. 
Where there is a disposition to a return of the affection, 
prophylactic measures are to be practised for some time after 
the attack has passed away ; relapses are common. No fears 
need be entertained concerning danger from retrocession ; 
the sooner the disorder disappears the better for the comfort 
of the patient. 

Prognosis. — In our climate the disorder is seldom obstinate ; 
it rarely continues, under appropriate treatment, longer than 
a few days. If neglected, however, it may pass into a der- 
matitis or into an eczema, and as such last indefinitely. 

It is most rebellious in fleshy persons, occurring about the 
natural folds of the skin, where it necessarily resolves itself 
into an erythematous or eczematous intertrigo. In children, 
also, it is a source of great discomfort, continuing, off and 
on, throughout the hot season. It is very apt to relapse in 
successive years. 

Dysidrosis. — Under this name Fox* has described a dis- 
ease of the sweat glands allied to miliaria, characterized by 
the retention in the ducts, of sweat which has been rapidly 
and freely secreted. It consists at first of minute, isolated, 
vesicular points, which are deeply imbedded in the skin. 
They do not incline to rupture. After they have existed for 
several days, they increase in size and assume a yellowish 
color, and now resemble small boiled sago grains implanted 
in the skin. As the process advances the vesicles become 
more distended, and elevated above the level of the sur- 
rounding skin, finally coalescing, and forming, in severe 
cases, small, irregularly-shaped bullae. There is still no dis- 
position on their part to break and discharge. In the course 
of some days the fluid is reabsorbed, the epidermis desqua- 
mating and leaving an abraded surface. The affection, pri- 
marily, is not attended with inflammatory signs; they may, 
however, occur secondarily. It occurs upon various regions 
of the body, as the hands, feet, face, neck, and trunk. In its 
slightest form it is confined to the hands, occurring especially 

* Loc. cit., p. 476. Also British Medical Journal, Sept. 27, 1873. 



PEMPHIGUS. 237 

upon the sides of the fingers and over the palm. One or 
both hands may be attacked. After the affection has existed 
for a while, the epidermis becomes macerated and soggy, 
and the skin is apt to be sore and painful. In severe cases, 
according to Fox, the eruption may extend itself over the 
backs of the hands and over the arms, resembling the course 
of an eczema; there are, however, no crusts present. The 
complaint is generally accompanied by itching and burning 
sensations, which may be very slight or severe, according to 
the extent and gravity of the case. It may continue from 
one to several weeks. It is observed to occur in those who 
usually perspire freely. It may occur either in summer or in 
winter, more often in the former. Those who suffer from 
the disorder are generally the subjects of nervous debility, 
weakness, dyspepsia, and other depressing conditions. In 
the several instances in which I have observed the affection, 
these symptoms were all present in a striking degree. 

The disorder manifestly has its seat about the sweat 
glands, and consists in an undue distention of the sweat 
duct throughout its entire course, followed by a collection 
of the fluid within the skin. It may be mistaken for vesic- 
ular eczema, although it lacks the inflammatory symptoms, 
and the discharge and crusting. In severe cases it may be 
followed by eczema, as in the case of miliaria. It is more 
closely allied to this last-named disorder, miliaria, than to 
any other, but differs from it in being a less acute process 
and being, moreover, unattended by inflammation. The 
treatment is to be directed against the general condition of 
the patient. The local remedies referred to in considering 
miliaria are to be employed. The affection is quite rare in 
this country. I have never encountered cases so extensively 
developed as those described by Dr. Fox. 

PEMPHIGUS. 

Syn. Pompholyx; Germ., Pemphigus ; Blasenausschlag ; Fr., Pemphigus. 

Pemphigus is an acute or chronic, exudative disease, char- 
acterized BY THE FORMATION OF A SUCCESSION OF IRREGULARLY- 
SHAPED BLEBS, VARYING IN SIZE FROM A PEA TO AN EGG. 

Symptoms. — There are two varieties of pemphigus, pre- 



238 EXUDATIONS. 

sen ting symptoms so different in character as to call for 
separate description. They are named pemphigus vulgaris 
and pemphigus foliaceus. The former of these is the variety 
commonly encountered, and is to be looked upon as the type 
of the disease. 

Pemphigus Vulgaris. — The disease may attack all por- 
tions of the body, and shows a marked tendency to appear 
without regularity of distribution over the whole surface, 
no part being exempt. It is most common, however, upon 
the limbs. It may also attack the mucous membrane of the 
mouth and vagina. I have known it to commence in these 
regions, the disease appearing later upon the skin. Occur- 
ring here the lesions are liable to be mistaken for syphilis, 
the bullae breaking down and closely resembling mucous 
patches. 

The lesions are blebs from the commencement to the end, 
and possess marked features. They form slowly or rapidly ; 
at times in the course of a day. Their number may vary 
from several to dozens ; usually a half-dozen or more may be 
seen at any period during the attack, while at other times 
much larger numbers occur. In size they vary from a pea 
to a walnut or a goose's egg; various sizes may always be 
observed in a given case. In form they are rounded, oval, 
semiglobular, or dome-shaped, and are elevated in a very 
prominent manner above the level of the surrounding skin, 
at times as high as an inch. Their walls are generally fully 
distended with fluid, giving them the appearance of being 
greatly stretched. They rise abruptly from the sound skin 
with a definite line of demarcation. In color they are yel- 
lowish. They contain a colorless fluid, which, however, 
becomes cloudy or puriform as they grow older. They 
rarely rupture spontaneously. They incline to no particular 
arrangement, but appear here and there, either singly or 
together; now and then they cluster in a somewhat semicir- 
cular manner. But little inflammation attends them, their 
bases being, as a rule, alone reddened ; the surrounding 
skin is only occasionally erythematous. Each bulla runs its 
course in from one to three or six days. A characteristic of 
these bullae consists in their successive appearance. One or 



PEMPHIGUS. 239 

a crop of them no sooner disappears than others show them- 
selves, and it is in this way that the disease runs its course. 
Itching and burning occur as a rule only slightly, the first 
of the symptoms being, perhaps, the most notable. At 
times, however, both of these sensations may be present 
in a marked degree, constituting great distress (pemphigus 
pruriginosus). 

Pemphigus in the adult is, as a rule, attended by signs of 
general disturbance of the system only in severe cases, and 
in unusual forms of the disease. In children, however, there 
is always more or less fever and constitutional derangement. 

The affection may be either acute (pemphigus acutus) or 
chronic (pemphigus chronicus), the latter course being the 
usual one. Acute pemphigus, indeed, is exceedingly rare, 
excepting in children, where it is usually observed to run its 
course in a few weeks or a month. Pemphigus in the adult 
has an essentially chronic course, often lasting years. 

The disease may be benign or malignant, according to the 
condition and health of the patient, hygienic surroundings, 
diet, and other causes which tend to influence the type of 
diseases in general. Malignant pemphigus (pemphigus ma- 
ligxus) is characterized by the great size and number of the 
bullae. They form very rapidly, coalesce, rupture, and are 
succeeded by excoriated surfaces, which not infrequently 
take on ulcerative action. Blood may also be poured out. 
which, in connection with a puriform exudation, is observed 
to collect upon the skin in the form of crusts. The 
patient's health is always seriously impaired in these cases. 
Itching and burning are at times present in a remarkable* 
degree. If the individual be cachectic, the disease inclines 
to an unfavorable termination (pemphigus cachecticus, pem- 
phigus GANGR^NOSUS). 

Pemphigus Foliaceus. — Here the bullae differ from those 
of pemphigus vulgaris in that they are not distended or 
tense. They are, on the contrary, flaccid and only partially 
filled with fluid, which seems rather to undermine the 
epidermis than to uplift it into blebs. This imperfect forma- 
tion of the lesion constitutes the chief peculiarity of the 
affection. The bullae rupture before arriving at a state of 



240 EXUDATIONS. 

full development, or the epidermis may be so readily de- 
tached from the true skin that large, loose, half filled, 
irregularly-shaped blebs are formed, which soon give way 
and collapse. They may also coalesce, thus involving a con- 
siderable surface. Usually the greater portion of the body 
is attacked, and not rarely the whole surface.* The bullae 
succeed one another with great rapidity and persistence, the 
same regions, moreover, being the seat of repeated attacks. 
In this manner large numbers of blebs are continually form- 
ing before the skin has had time to regain its normal state. 
In this respect, as regards its course, the disease is similar to 
chronic eczema vesiculosum. When the disease has existed 
for a time the skin presents a white, flaky appearance; the 
epidermis is loose, torn, and has a shreddy, ragged look. It 
has been well compared to a superficial scald. The fluid, 
never very abundant, dries immediately into thin whitish 
flakes, which are quickly detached and cast off in quantity ; 
beneath is seen an excoriated, red surface, — the rete and 
corium. The process is invariably a chronic one, and may 
continue for years. Sooner or later the general health be- 
comes seriously disturbed, profound prostration supervenes, 
and very often the patient succumbs. It is, happily, a very 
rare form of disease. 

Etiology. — Pemphigus is an uncommon disease. It is, I 
think, of less frequent occurrence in this country than in 
Europe. White, in Boston, reports having met with fifteen 
cases only out of five thousand consecutive cases of skin 
disease in dispensary practice, a large proportion of these 
having occurred in infants, f According to my experience, 
the percentage in Philadelphia is even less. 

* I recall the case of a man, some forty years of age, and otherwise in 
apparently perfect health, who was afflicted with this variety of the disease 
in its universal form. There was not a square inch of healthy tissue upon 
his surface, the fingers even being affected. He was a patient in the Vienna 
General Hospital under the care of Professor Hebra. I noted the course of 
the disease, from time to time, for a year and a half, at the expiration of 
which period the man was still in a most distressing state. The continuous 
plain water bath, in which he lived for months, afforded him more relief 
than any other mode of treatment. 

f Boston Med. and Surg. Jour., March 23, 1876. 



PEMPHIGUS. 241 

It is said to occur in all parts of the world. The causes 
are very obscure. The disease is much more common in 
children than in adults. After the period of infancy and 
childhood it occurs at all times of life in about the same 
frequency. Both sexes suffer in the same proportion. It 
occurs with equal frequency at all seasons of the year, and 
does not appear to be influenced by atmospheric causes. 
Articles of food, as a rule, have no cause in its production, 
although a low and improper diet may in certain cases de- 
termine the disease. Functional derangement in females is 
now and then found to be associated with the disease, but 
can scarcely be viewed as a cause. Pemphigus has been 
noted to show itself first during pregnancy. It is prob- 
ably of more frequent occurrence in persons of florid com- 
plexion. Mental depression has been observed to precede 
pemphigus, and in some cases may be viewed as the cause. 
The only recognized origin of the disease is to be found in 
a state of general debility, nervous prostration, and loss of 
normal tone. This condition always precedes and accom- 
panies a certain number of cases; it cannot, however, be 
considered as the only cause of the disease. There are 
other cases where the general health to all appearances is 
good. Pemphigus is not contagious. 

Syphilis is never a cause of pemphigus. It, however, as 
is well known, occasionally gives rise to a bullous eruption, 
resembling pemphigus, but with a different train of clinical 
characters, which are and can be produced only by syph- 
ilis. The so-called syphilitic pemphigus (pemphigus syphi- 
liticus) is manifestly a bullous syphiloderm, and not a true 
pemphigus. 

Pathology. — The disease consists in the successive produc- 
tion of bullae, which, according to the observations of Simon 
and Hebra, differ in no respect, as regards their anatomical 
structure, from other bullae. 

Hebra* describes the mode of their appearance as follows. 
"Sometimes a circumscribed light red spot appears, per- 
haps of the size of a bean or large coin ; this is paler in the 



Loc. cit., vol. ii. p. 
16 



242 EXUDATIONS. 

centre, and may even present a tinge of white, indicating 
the point at which the bleb is to form, and from which it 
will spread outwards over the surrounding red surface. In 
other cases the spot, besides being red, is raised above the 
level of the surrounding skin, and in fact is at first a wheal, 
passing afterwards into a bleb. In other cases the bleb is 
not preceded either by a red spot or by a wheal, but begins 
originally as a small collection of clear fluid beneath the 
cuticle. Thus hyperemia of the skin may exist before 
exudation is poured out, or the latter may be formed before 
any congestion of the papillary layer is discoverable." 

The contents of the bullae are yellowish or colorless, and 
consist of serum or, in later stages, of a puriform fluid ; 
blood is also occasionally present. The reaction is either 
neutral or alkaline. According to Hebra, the older the 
fluid the more alkaline it becomes. 

The contents of the bullae, the urine, and the blood have all 
been submitted to chemical analysis, but without obtaining 
knowledge as to the more intimate nature of the disease. 

Diagnosis. — E"o difficulty should be experienced in the 
diagnosis of typical cases. It must be remembered, how- 
ever, that the mere presence of blebs does not necessarily 
constitute pemphigus, inasmuch as these are at times devel- 
oped in other diseases, as well as by artificial means. But 
when their appearance together with their course is taken 
into consideration, and the fact that in pemphigus they 
always occur in successive crops, the diagnosis may usually 
be made. 

Herpes iris is the disease which bears the closest resem- 
blance to pemphigus. The following points of difference 
may be noted. Pemphigus in the adult is for the most part 
a chronic affection, continuing for months or longer ; herpes 
iris is always acute, running its course in a few weeks. In 
pemphigus full-sized blebs may always be noted ; in herpes 
iris the lesions are usually vesicles, which may attain to the 
size of blebs. The varied colors which invariably encircle 
the vesicles of herpes iris throughout their course, are never 
present in pemphigus, nor is the surrounding skin in this 
latter disease usually so inflamed. The vesicles of herpes 



PEMPHIGUS. 243 

iris are always arranged concentrically, and increase in this 
manner; the blebs of pemphigus incline to no such ar- 
rangement. The seat of the disease in herpes iris — usually 
upon the arms, backs of the hands, and lower limbs — is 
quite characteristic; in pemphigus the disease has no seat 
of predilection. 

Scabies sometimes presents quite large vesicles, and even 
bullae, but the general symptoms and course of the disease 
will always render it distinguishable from pemphigus. Pem- 
phigus can scarcely be confounded with eczema. 

The bullous syphiloderm is to be diagnosed from pem- 
phigus by the fact that it dries into thick, bulky, greenish 
crusts. Beneath these crusts there always exists an ulcer, 
which secretes a greenish-yellow, unhealthy product, mingled 
with blood. Other symptoms of syphilis (in children as well 
as in adults) may usually be found in connection with the 
bullous syphiloderm, which will prevent error as to the 
nature of the lesion. The bullae of erysipelas can never be 
mistaken for those of pemphigus. 

It happens at times that bullae are produced by artificial 
means on the part of patients, for the purpose of feign- 
ing disease. The various stronger acids, especially nitric, 
dropped or painted upon the skin, cause these lesions to 
appear, at times in a very perfect manner.* Where such 
a cause is suspected, the patient should be placed under 
careful surveillance, when the deceit, if there be any, will 
readily be detected. 

Treatment. — Both internal and external treatment are of 
service, but especially the former, which must be directed 
against the supposed cause. The case should first of all be 
attentively studied, after which the treatment determined 
upon as most suitable should be rigidly enforced and per- 
sisted in. Constitutional remedies are of the utmost im- 



* A case of feigned pemphigus in a young girl, in G-uj-'s Hospital, London, 
whom I was invited by Dr. Fagge to see, is called to mind. The bullae 
were numerous, and in appearance differed in no way from those of genuine 
pemphigus. The artificial nature of the lesions was suspected, and observa- 
tion subsequently proved that they were produced by nitric acid, although 
the girl stoutly denied that such was their origin. 



244 EXUDATIONS. 

portance in all cases where there is general impairment of 
the health, debility, and prostration. Functional disorders 
should be inquired after, and the various secretions care- 
fully examined. The digestive system should be regulated, 
if disordered, by means of laxatives and tonics. Arsenic is 
the most valuable remedy which we possess for this disease. 
It should be given in small doses, and its employment per- 
sisted in. Hutchinson* considers it in the light of a specific. 
Quinine is of value as a general tonic, and also in those cases 
in which the bullae are preceded by fever ; it should be pre- 
scribed in full doses and its administration continued for 
some time. 

Of quite as much importance as the use of drugs are 
matters of diet and hygiene. In a large number of cases 
there is a failure of accustomed health, which is often only 
to be restored by proper nourishment and strict attention to 
the laws of hygiene. The food should be of the best quality 
and suitably prepared. A full animal diet, including meat, 
eggs, milk, and cream, should be generously given. Cod- 
liver oil should be ordered in all cases where the stomach will 
bear it. Wine or ale, in proper quantities, may likewise be 
directed with benefit in certain cases. Fresh air, and exer- 
cise when practicable, are to be insisted upon. Rest and 
freedom from mental distress are also to be secured, and, 
indeed, everything should be done to make the patient as 
comfortable as possible both in body and in mind. In chil- 
dren the same general principles are called for ; the means 
are to be modified to suit the case. 

The local treatment should always receive careful atten- 
tion, for in certain rebellious cases, in which nothing appears 
to avail in arresting the process, this may constitute the only 
means of affording relief. The blebs should be punctured 
and evacuated as soon as they have formed ; if they refill, 
the proceeding is to be repeated. A dusting powder, com- 
posed of equal parts of oxide of zinc and starch, serves as a 
useful dressing where the bullae occur over a large surface 
and in great numbers. 

* See Medical Times and Gazette, vol. ii., 1875, pp. 461, 513, 565. A most 
valuable contribution to the subject. 



PEMPHIGUS. 245 

The bath offers a most acceptable and beneficial method of 
treatment for all cases. It may be employed either as plain 
water or in connection with medicinal substances. The tar 
bath, in which the patient is rubbed with one of the oils of 
tar, and then placed in tepid water and allowed to remain 
there for an hour or longer, is often useful in those cases in 
which this substance is tolerated. In some instances the 
bran, starch, or gelatine bath affords greatest relief. Hebra 
has used with benefit the corrosive chloride of mercury 
bath, in the strength of one-third of a grain to the pint of 
water; also caustic potassa, in the form of a bath, in the 
strength of half a grain to the pint of water. 

The best local treatment, for grave cases, is to be found 
in the continuous bath, as recommended by Hebra. This 
consists in permitting the patient to remain in a specially 
prepared bath-tub for days, weeks, or months, according 
to circumstances. In the tub are to be placed a horse-hair 
mattress and pillows, upon which the patient may rest com- 
fortably. The water is to be kept sufficiently warm, and to 
be changed from time to time throughout the twenty-four 
hours. The patient, in almost every instance, experiences 
great relief from the continuous bath, and will ordinarily 
prefer it to all other methods of local treatment. The pain, 
itching, and burning sensations, so severe in grave cases, are 
relieved by this means, and the patient afforded ease and 
comfort in his affliction. The simple water applied in this 
uninterrupted manner for weeks or longer seems to exert a 
decided curative effect, and must be considered as one of the 
most satisfactory methods of treating this disease locally.. 
The patient may remain in the bath, eating and sleeping 
and living in it, for an almost indefinite period without in 
any way interfering with the general health.* 

* The continuous bath has been for some years past employed by Hebra, 
in whose hands it has proved a serviceable method of treating pemphigus. 
As to the length of time which patients have remained in the water, for 
various diseases, Hebra has repeatedly kept them in the bath for months (in 
some cases as long as two hundred and seventy days) continuously, allowing 
them to come out of the water only for the evacuation of the bowels. 

For a more detailed account of the bath and its action, see Prof. Hebra's 



246 EXUDATIONS. 

Where the bath cannot be employed, water dressings by 
means of cloths may be substituted. There are cases, how- 
ever, in which water, owing to some idiosyncrasy, does not 
appear suitable, or in which it is not considered advisable to 
use it. In these instances ointments may be directed, none 
being better than either the oxide of zinc or diachylon oint- 
ment. Whichever is selected should be applied upon cloths 
and bound down to the part with bandages. 

Prognosis. — ISTo disease runs a more arbitrary or uncer- 
tain course than pemphigus. Relapses are common. The 
ultimate result can scarcely be predicted. In adults the 
prognosis should always be considered with deliberation. 
Very much depends upon the character of the bullae, their 
number, the rapidity of formation, and their generalization 
as regards distribution. If they are flaccid, imperfectly 
formed, and inclined to rupture, the prognosis is unfavor- 
able. When in large numbers, involving an extensive sur- 
face, and characterized by the rapidity and frequency of 
their formation, the result must in like manner be viewed 
with caution. The general condition of the health is to be 
considered. Repeated febrile attacks, together with impair- 
ment in strength, point to a serious termination. Opinion 
should in all cases be guardedly expressed, for the disease 
is one indicating severe systemic disturbance. In grave 
cases the process may end fatally. 

LICHEN PLANUS. 

Syn. Lichen Ruber (Hebra). 

Lichen planus is an exudative disease, characterized by 
pin-head or pea- sized, plat, angular, smooth, shining, deep red, 
discrete or confluent papules, having a chronic, distinctly 
papular or papulo-squamous course, attended by more or less 

ITCHING. 

Symptoms. — The disease is one of the most peculiar of the 
papular group, possessing features which serve to make the 

work upon Diseases of the Skin, Trans, of the New Syd. Society, London, 
vol. i. p. 320; also, second German edition of the same work (1874), vol. i. 
p. 273. 



LICHEN PLANUS. 247 

process definite and distinctive. The papules vary in size 
from a pin-head to a split pea; where several have coalesced, 
as occurs in the later stage, they appear even larger, existing 
in the form of small, plate-like patches. In shape they differ 
from all other papules, in that they are not round but angular, 
having a somewhat square form. They rise abruptly from 
the healthy skin, above which they are elevated from half a 
line to a line, are flattened on their tops, and show at times 
slight umbilication. To the touch they are firm and solid. 
They have, in their early stage, a smooth surface, are free of 
scales, and have a glistening or glazed appearance ; later, in 
those cases where the process runs into a papulosquamous 
stage, considerable desquamation may be present. In color 
they possess a dull red or even violaceous hue. The lesions 
are usually discrete, though, when existing in numbers, they 
incline to coalesce and form patches; when this occurs, they 
lose the characteristics of papules, and assume the appearance 
of elevated, flattened patches of infiltration. 

The disease may show itself either in the form of localized 
areas or as a diffused eruption, involving a large portion of 
the surface. The localized form is that usually met with. 
Here the lesions consist of one, two, or more a^^re^ations 
of papules, which may exist either upon a limited extent of 
surface, as, for example, an arm, or upon quite different 
regions of the bod} 7 . The papules themselves may be dis- 
seminated or closely crowded together, in the form of a solid 
patch. The diffused form* of lichen planus may occupy a 
part or the whole of the body, appearing either as numerous, 
isolated patches or in the form of extensive sheets of erup- 
tion. When this takes place the papules are quite small, 
pin-head in size, and are scantily covered with thin, whitish, 
micaceous scales. 

The affection commonly presents itself upon the arms, 
legs, thighs, and abdomen. Its course is extremely slow, 
months frequently elapsing without there being any appre- 
ciable change in the lesions; the process may continue for 

* This variety of the disease constitutes the Lichen Kuber of Hebra. and is 
chiefly encountered in Austria; it is rarely, if ever, met with in this country. 



248 EXUDATIONS. 

years. The severe form (lichen ruber) runs even a more 
chronic course, and is attended by a train of serious symp- 
toms, including constitutional disturbance, marasmus, and, 
at times, a fatal termination. 

Etiology. — The causes are in many instances obscure. Wil- 
son* is of the opinion that the disease is always associated 
with symptoms of constitutional derangement connected 
with errors of the digestive and nutritive system, a view 
which is likewise entertained by both Foxf and Taylor.J 

Patients will not infrequently be found to be suffering from 
general debility arising from improper nourishment, over- 
work, nervous depression, and similar conditions. The dis- 
ease occurs at all periods of life, but is more frequent during 
middle age. It is more common in women than in men. It 
is a rare disease in this country. According to Wilson, it is 
not uncommon in England. § 

Pathology. — The disease is to be regarded as an exudation 
of a chronic nature, accompanied by considerable alteration 
in the structure of the skin. It will be remembered that 
two forms of the affection are met with. Microscopical 
studies have for the most part been undertaken upon chronic 
cases. According to Neumann|| and Biesiadecki,Tf the dis- 
ease involves nearly all the layers of the skin as well as the 
sebaceous glands and hairs. The cells of the epidermis are 
accumulated in great quantity, and contain fine granular 
matter. The rete is highly developed over and around the 
cedematous papillae, which are considerably enlarged and 
contain bloodvessels abnormally large, along the course of 
which there exists an abundant proliferation of cells. 

Biesiadecki is of the opinion that each papule in its gen- 

* Diseases of the Skin, London, 1867, p. 192. 

f Loe. cit., p. 146. 

X Archives of Dermatology, vol. i. No. 1. An interesting report of cases. 

\ See a valuable paper by Mr. Wilson, reporting a large number of cases, 
in the Journal of Cutaneous Medicine, vol. iii. No. 10, 1869. Mr. Wilson 
was the first to describe the disease under consideration, and gave to it the 
name by which it is known. 

|| Loc. cit., p. 238. 

\ Untersuchungen aus dem Pathologisch-Anatomischen Institute in Kra- 
kau, p. 32. Wien, 1872. 



LICHEN PLANUS, 249 

eral structure consists of two parts, a central, atrophic por- 
tion, corresponding to the umbilication which is frequently 
observed clinically, and a peripheral, succulent, oedematous 
portion, and that these features distinguish the papules 
under consideration from those of other diseases. 

Interesting changes are also noted by both the observers 
quoted, in connection with the roots of the small hairs, 
which are seen to terminate abruptly in the form of tuft-like 
expansions. The root sheaths are also found to be greatly 
hvpertrophied around the roots of the hairs, and to be dis- 
tended by cell infiltrations to such an extent as to form 
knotty, club-shaped extremities. Hypertrophy of the mus- 
cles of the skin is also present. 

Diagnosis. — Lichen planus may be mistaken for the papu- 
lar syphiloderm, lichen scrofulosus, and eczema papillosum. 
The irregular, angular outlines of the lesions, together with 
their flattened, slightly umbilicated, smooth, dull red, shining 
tops, will, however, be points sufficiently distinctive to sepa- 
rate the disease from these affections. The papules of eczema 
papillosum, to which they bear the greatest resemblance, 
are roundish, somewhat acuminated, bright red in color, in- 
tensely itchy, and possess a history very different from those 
of lichen planus. 

Treatment. — A general tonic and supporting treatment is 
demanded in the majority of cases. The preparations of 
iron, arsenic, and cod-liver oil prove the most valuable and 
effective remedies against this troublesome and stubborn 
affection. The sooner in the course of the disease treat- 
ment is instituted the more speedy will be the cure ; cases 
of long standing are found to be exceedingly obstinate and 
rebellious, continuing for long periods but slightly influ- 
enced by remedies which in an earlier stage would have 
afforded relief. Hygienic measures, adapted to the require- 
ments of the case, will be found to aid in bringing about a 
favorable result. The best of food should be directed, and 
everything done to improve the general condition of the 
patient. 

The local treatment should consist of those applications 
which, by experience in the case, are found to afford the 



250 EXUDATIONS. 

greatest amount of relief; inunctions with simple ointment, 
tar ointment of various strengths, alkaline lotions and baths, 
carbolic acid lotions, varying in strength from one to three 
drachms to the pint of water, may all be employed for this 
purpose. In addition to these, the various stimulating reme- 
dies useful in eczema may be prescribed with the hope of 
success. 

Prognosis. — This will depend upon the severity of the 
case, the amount of surface involved, and the duration of the 
disease. Where the lesions are localized and not extensive 
the prognosis is favorable, provided the proper treatment 
can be carried out. In the diffused form of the disease, 
months and years may pass without there being much 
change for the better; in very severe cases a fatal termi- 
nation may even take place. 

PRURIGO. 

Syn. Germ., Prurigo (Hebra) ; Juckblattern ; Fr., Strophulus Prurigineux 
(Hardy); Scrofulicle Boutonneuse Benigne (Bazin). 

Prurigo is a chronic, exudative disease, characterized 
by numerous, discrete, rounded, small split-pea sized, solid, 
firmly seated, slightly raised, pale red papules, accom- 
panied by general thickening of the skin and intense and 
constant itching.* 

Symptoms. — The disease commences by the slow and grad- 
ual formation of small, solid elevations, which have their 
seat in the skin itself, appearing to be situated in a measure 
beneath the epidermis. At first they are often so slightly 
elevated as to escape being seen, but they may always be 
felt by passing the finger over them. When fully developed 
they are observed to be rounded, raised only to a very slight 
extent, and about the size of small split peas. They are 
remarkably solid in consistence, and may be detected by 
the finger as hard, shot-like bodies, imbedded in the skin. 
They exist discretely, although often in close proximity to 
one another; they are never grouped, but always more or 
less irregularly distributed. In color they are pale red, or 

* The term prurigo is used in the sense attached to it by Hebra. 



PRURIGO. 251 

like that of the normal surrounding skin itself. They are 
frequently covered with a scanty, dry, shrivelled epidermis, 
but never to the extent of scales. They are frequently per- 
forated by small hairs. 

The eruption is accompanied by intense itching, which 
symptom manifests itself very early, and remains present 
throughout the entire course of the disease. It is usually 
of so violent a nature that the patient is unable to desist 
from scratching, and consequently lacerates the lesions, as a 
rule, before they have completely formed. From repeated 
and protracted scratching the tops of the papules become 
torn, and ooze forth a small quantity of bloody serum, which 
rapidly dries into a crust. Hence, at all times these blood 
crusts are present, and constitute a constant secondary lesion 
of the affection. As the disease progresses, the itching and 
scratching increase to such an extent that excoriations result. 
In course of time a peculiar thickening of the skin takes 
place, attended by a rough, harsh condition of the surface, 
which is characteristic of the disease and may be recognized 
by the touch. It is invariably most marked about the lower 
extremities. The hairs here are seen to be either broken 
off short or to be torn from their follicles, the result of 
scratching. 

The eruption has its seats of predilection. It attacks by 
preference the extensor surfaces of the lower extremities, 
especially the region of the tibia, where it may always be 
found prominently developed. The arms, particularly the 
forearms, are next invaded, and finally the trunk. The 
head is rarely if ever attacked; the palms and soles never. 

In severe cases, owing to the great irritation and conse- 
quent scratching, the glands of the inguinal region become 
enlarged and constitute "prurigo buboes," as Hebra has 
termed them; they occur symmetrically. Pigmentation of 
the skin is another symptom which shows itself in cases 
where the complaint is exteusive and of long standing; it is 
probably a result of the scratching, and in this case is to be 
viewed as of the same nature as that observed in those cases 
where phtheiriasis has existed for a long period. 

The disease almost invariably appears at an early age, and 



252 EXUDATIONS. 

runs a very obstinate and chronic course, lasting usually 
throughout life. Eczema may at times be called forth by the 
inordinate scratching, as well as by the strong cutaneous irri- 
tants and caustics which are used for the relief of the disease. 

Etiology. — The disease is extremely rare and almost un- 
known in the United States.* It is only occasionally 
encountered in France and England, f but is common in 
Austria, where it may be said to have its home. It is never 
hereditary, although it always shows itself at an early age, 
not infrequently before the tenth year; nor is it contagious. 
According to Hebra, it is more often encountered among j 
males than among females. 

Prurigo is emphatically a disease of the poor; its causes 
are to be found in impoverished conditions, of the system, 
occasioned by bad food, improper hygiene, and general 
neglect. Hebra justly remarks that " it undoubtedly occurs 
almost exclusively in poor subjects and those ill nourished 
in childhood, and so most often in foundlings and beggars' 
children. Those who have enjoyed a good physical education 
in early youth, and have always been properly fed according 
to their age, suffer very rarely indeed from prurigo." 

The affection is found to be worse in winter, the summer 
months always proving most beneficial for those afflicted 
with this tormenting disease. 

It is scarcely necessary to state that prurigo is never pro- 
duced by pediculi or other parasites. 

Pathology. — The microscopic anatomy of the prurigo papule 
has received careful study at the hands of Hebra, R. H. 

* The only reported case occurring in this country will be found in the 
Amer. Jour, of Syph. and Derm., vol. iv. p. 21, 1873, recorded by Wiggles- 
worth, of Boston. 

f Among certainly many thousand cases of skin disease which I had, some 
years since, the opportunity of observing at the Hopital St. Louis, Paris, one 
case only of the prurigo of Hebra presented itself. It occurred in a lad 
about sixteen years of age, and was a marked example of the disease. Prof. 
Hardy, who was present, informed me that he designated the affection Stro- 
phulus Prurigineux. 

In London, among a large number of cutaneous diseases as met with at 
the various special hospitals and dispensaries, I do not recollect seeing a 
single case. 



PRURIGO. 253 

Derby of New York,* Neumann, and Gay.f The views of 
Neumann and Gay are alike as to the origin of the disease ; 
both these observers hold that the process begins in the 
papillary layer, the papule being formed by a circumscribed 
accumulation of young cells, with a certain amount of struc- 
tureless fluid exudation. As the disease progresses, the 
epidermis and rete become highly developed and more or 
less pigmented. Neumann states that he found the whole 
papillary layer and the corium hypertrophied and greatly 
thickened by the formation of a firm connective tissue. The 
outer root sheath was increased considerably in size, and 
the hair follicle expanded in the form of a club. Gay, in 
addition, determined the sweat glands and the vessels of 
the skin to be enlarged. 

Diagnosis. — If the peculiar features of prurigo be borne in 
mind, no difficulty can arise in its diagnosis. It will be seen 
that a distinct, clearly-defined disease has been described, 
which bears no relation whatever to either of the affections 
with which prurigo has long been confounded, — namely, 
pruritus and phtheiriasis. By reference to these latter dis- 
eases, their characters will be noted to be very different 
from those of prurigo. It will also be remembered that 
prurigo is an exceedingly rare, almost unknown, affection 
in this country. 

Prurigo may be diagnosed from pruritus by the presence 
of the papules, which are primary ; in pruritus no papules 
exist, except those produced by scratching, which, of course, 
are secondary. 

Blood crusts exist in both prurigo and pruritus; they are, 
however, much more numerous in prurigo, and are seen to 
be seated about the apices of the torn and wounded papules. 
Prurigo is always attended with remarkable thickening of 
the skin ; such is rarely the case in pruritus, and never to 
the same extent. The peculiar roughness or harshness of 
the skin in chronic prurigo is characteristic; it is never seen 
in pruritus. The regions attacked in prurigo are different 

* Sitzungsberichte der Kais. Akad. d. Wissenschaft. Wien, Febr. Heft, 1869. 
f Archiv fiir Derm, und Syph. Erstes Heft, 1871. Translation in the 
Amer. Jour, of Derm, and Sypb., vol. ii. p. 261. 



254 EXUDATIONS. 

from those usually invaded by pruritus; in the former dis- 
ease the extremities, more especially their extensor surfaces, 
are always involved, while in the latter the trunk or all parts 
of the body may be the seat of the trouble. The itching of 
prurigo is intenser, deeper-seated, and more constant than 
that of pruritus, and is relieved only by means which act 
upon the papillary layer of the skin itself, as, for example, 
violent scratching or caustics. Prurigo usually begins before 
puberty, and continues throughout life; pruritus seldom ap- 
pears before adult age, runs a very variable course, and very 
frequently disappears, either with or without treatment. Pru- 
rigo is seen almost exclusively upon the poorly nourished and 
ill fed ; pruritus is often encountered upon those who are in 
good general health, having its cause very frequently in some 
slight functional derangement of the economy. 

Prurigo should not be confounded with phtheiriasis. The 
two diseases have nothing in common. Pediculi are never 
present in prurigo; they are the sole cause of phtheiriasis, 
and consequently are always present. Small papules, due to 
scratched and inflamed follicles, covered with blood crusts, are 
at times seen in phtheiriasis ; but these are very different from 
the papules of prurigo, both in appearance and in course. 
The so-called papules of phtheiriasis are due to the bite of 
the pediculus, and the subsequent scratching of the part. 

Prurigo may be confounded with eczema. As already 
stated, eczema may exist as a complication, especially when 
the prurigo is very severe ; in this event the prurigo will be 
found to remain after the eczema has disappeared. The two 
diseases are, however, so different as not to permit of con- 
fusion otherwise than when they occur together, and even in 
such a case they may always be distinguished. The papules 
of prurigo run a very different course from those of eczema.* 



* It will be observed that the author differs in his ideas of prurigo from 
the majority of English and American writers. The disease, as described, 
is a marked one, possessing a peculiar clinical history, and is entitled to be 
clearly separated from the other affections with which it has long been con- 
founded. Prurigo, pruritus, and phtheiriasis are three very different diseases ; 
and yet, one has but to turn to the literature of the day to find sad confusion. 
The difficulty has arisen from the fact that prurigo, as described by German 



PRURIGO. 255 

Treatment. — From a consideration of the cause of the dis- 
ease, it will be evident that immediate attention is to be 
directed to the general condition of the patient. The diet 
is to be ordered and insisted upon ; it should consist of the 
most nutritious articles of food, including meats, milk, and 
eggs in generous quantity. Strict hygienic measures are to 
be instituted, and everything that will tend to improve the 
state of the patient's health taken into consideration. Iron 
and cod-liver oil are to be prescribed and taken for some 
time; other remedies of a similar kind may also be adminis- 
tered from time to time. This general plan of treatment is 
to be persistently persevered in, for the disease is an exceed- 
ingly obstinate one, and is to be relieved only by the most 
heroic measures. 

Very great benefit is to be derived from external reme- 
dies, chief among which are to be mentioned the various 
kinds of baths, simple and medicated. Tar and sulphur are 
the two most valuable remedies ; they are to be used in the 
form of frictions, and to be followed by a bath, as in the case 
of chronic and obstinate psoriasis. Wilkinson's ointment, 
as modified by Hebra,* has been used with marked benefit, 
and is highly spoken of by Hebra and Neumann. It, as well 
as other similar remedies, is used exactly as in the treatment 
of scabies. f 

Prognosis. — The disease is always a serious and obstinate 
one, usually lasting years, or even a lifetime. It is said to 
be curable in the child, but scarcely so when it has lasted 
until adult life. 

writers, is an affection so rare in England and the United States as scarcely to 
exist in these countries, and is consequently unknown to observers. Both 
pruritus, and phtheiriasis of the body, however, are sufficiently common, 
and are often attended by the formation of hyperaemic elevations (especially 
about the follicles), followed by blood crusts from scratching, which lesions 
have, very erroneously, been termed the papules of prurigo. In this manner, 
through serious complications, have the names of these three diseases been 
used interchangeably. 

Dr. Fox, in the last edition of his work, is the first English writer who 
has even attempted to draw the line of distinction between these affections. 

* See formula in the chapter devoted to the treatment of Scabies. 

f For detailed description of the various methods of treatment employed 
for this disease, see Hebra's interesting account, as given in his work. 



256 EXUDATIONS. 

LICHEN SCROFULOSTJS. 

Lichen scrofulosus is a chronic, exudative disease, char- 
acterized BY MILLET-SEED SIZED, REDDISH OR YELLOWISH, MORE 
OR LESS GROUPED, DESQUAMATING PAPULES, UNACCOMPANIED BY 
ITCHING, OCCURRING IN THOSE OF SCROFULOUS DISPOSITION. 

Symptoms. — The papules are always small; never larger 
than pin-heads. They are pale red, reddish, or yellowish in 
color; at times, owing to the accumulation of minute scales 
upon their tops, they present a grayish aspect. They show 
more or less disposition to group, forming roundish or cres- 
centic patches of various size in different parts of the body. 
These patches, when they have existed for some time, are 
usually covered with fine, branny, whitish scales. The pap- 
ules, when examined closely, are found to have their seat 
about the hair follicles. They are accompanied by little or 
no itching. 

The disease occurs chiefly on the trunk, more especially 
about the regions of the chest and abdomen ; more rarely it l : 
is seen on the limbs. Its course is exceedingly chronic, the 
individual lesions being slow to undergo involution ; it may 
last for years, old papules gradually disappearing and new 
ones taking their place; more or less desquamation is always 
present. The skin, as a whole, of patients with scrofulous 
lichen is apt to be dry, somewhat harsh, and of a yellowish hue.* 

Etiology. — The affection is rare in this country; it is most |»; 
frequently encountered in Austria, where it was originally 
described by Hebra. Its cause is found in the scrofulous 
habit, nearly all those in whom the disease is observed 
being affected with glandular enlargements, bone trouble, 
etc. It is seen in both children and adults. In Hebra's 
experience it occurs very much oftener in males than in 
females, especially in the case of adults. 

Pathology. — The anatomy of the lesions, excised from the 
liviug subject, has been studied by Kaposi, f as follows. Each 



* A representation of the affection under consideration may be found in 
Hebra's "Atlas der Hautkrankheiten." III. Lieferung, Taf. 3. 

f Lehrbuch der Hautkrankheiten, Hebra und Kaposi. Erster Bd. Zweite 
Auflage, 1874, p. 385. 



•::. 



ao'e. 257 

papule has its seat about the opening of a hair follicle, and 
is seen to consist of an epidermic collection. The patho- 
logical process is an exudation and cell-infiltration in aud 
about the hair follicles, sebaceous glands, and papillse around 
the aperture of the follicles. 

The exudation, Kaposi holds, commences at first around 
the vessels and at the bases of the follicles and glands, and 
later invades the iuterior of these structures. The cells col- 
lect in great numbers within the follicles and glands, to 
such an extent as greatly to distend them, thus forming the 
papules, and finally cause separation of the hairs from their 
sheaths. 

The process may disappear without leaving cicatrices, or, 
on the other hand, it may be followed by pit-like, atrophic 
depressions at the seat of the follicles. 

Diagnosis. — The affection is not to be confounded with 
eczema papillosum, from which it materially differs in not 
itching. It is also to be distinguished from lichen planus, 
more particularly in its later stage, — the lichen ruber of 
Hebra, — and from lichen pilaris, to which it bears likeness. 
The history of the case, the general condition of the patient, 
and the course of the disease, will suffice to determine the 
nature of the disorder. 

Treatment. — The disease always yields to treatment. Cod- 
liver oil, taken internally and applied externally, is the 
remedy recommended, which, according to Hebra, never 
fails in relieving the condition. The dose of the oil should 
be full, and its exhibition continued for a sufficiently long 
: period. Suitable diet should also be prescribed. 

ACNE. 

Syn. Acne Vulgaris; Acne Disseminata; Varus; Stone-pock; Whelk; 
Germ., Finnen ; Fr., Acne ; Acne Boutonneuse. 

ACNE IS AN INFLAMMATORY. USUALLY CHRONIC DISEASE OF THE 
SEBACEOUS GLANDS, CHARACTERIZED BY THE FORMATION EITHER 
OF PAPULES, TUBERCLES, OR PUSTULES, OR A COMBINATION OF 
THESE LESIONS, OCCURRING FOR THE MOST PART ABOUT THE FACE. 

Symptoms. — Acne may appear alone, as a well-defined dis- 
ease, or it may exist in connection with other affections of 

17 



258 EXUDATIONS. 

the sebaceous glands, as, for example, comedo and sebor- 
rba3a. 

It shows itself in the form of pin-bead to pea-sized eleva- 
tions, situated around the openings of tbe bair follicles and 
sebaceous glands; they maybe either papular, tubercular, 
or pustular in their nature. Usually tbe disease is seen to 
exist exhibiting both papules and pustules in all stages of 
their development, from the incipient inflamed gland and 
follicle to the same in its suppurative stage. They are more 
or less inflammatory, but are seldom accompanied by marked 
burning or itching. Yery often they give rise to no sub- 
jective symptoms whatever, except a feeling of soreness 
when touched or handled. In color they are reddish, with 
a central point which is usually yellowish and the seat of 
suppuration. The number of acne papules or pustules pres- 
ent varies extremely ; there may be only two, three, or a 
half-dozen, or, as is usually the case, a large number, scat- 
tered over the region. 

The inflammation may be quite superficial, or it may ex- 
tend deeply into the glands, occasioning considerable swell- 
ing and disturbance; not infrequently abscesses are formed. 
The inflammation may be acute or chronic, running its 
course either rapidly, in a few days' time, or sluggishly, 
lasting several weeks or longer. The disease, taken as a 
whole, is almost always chronic in its course, crops of pap- 
ules and pustules appearing from time to time, the process 
frequently continuing for years. According as the disorder 
has been more or less suppurative will cicatrices remain; 
these may be slight or very disfiguring. 

Acne may occur upon any portion of the body except the 
palms and soles, but it has very decided preference for cer- 
tain regions. Its common seat is about the face ; it is also 
frequently seen upon the shoulders and upon the back. It 
occurs upon all parts of the face, and, in particular, about 
the forehead, cheeks, and chin. In certain cases, the shoul- 
ders are often attacked at the same time with the face. The 
eruption does not come out with any regularity of distri- 
bution, but breaks forth indiscriminately and often without 
symmetry over the region invaded. 



ACNE. 259 

It varies greatly as regards development and general ap- 
pearance, constituting either a slight disorder or a grievous 
disturbance, attended by serious disfigurement and annoy- 
ance. It is one of the commonest diseases of the skin. 
It occurs chiefly in young people of both sexes, appearing 
ordinarily at the age of puberty. It rarely, if ever, shows 
itself before this period of life, and seldom is present after 
mature years; there are, however, exceptions in which it 
tends to continue for years. 

The varieties of aerie may now be referred to. Of these 
I make two; they are named according to the anatomical 
lesions usually observed in the course of the disease. 

Acne Papulosa. — This variety consists in the formation 
of pin-head or pea sized papules, occurring about the 
openings of the sebaceous ducts. They are usually quite 
small, and partake somewhat of the nature of comedones. 
The amount of inflammation is ordinarily slight. A dark 
point may frequently be seen in the centre of the papule, 
which has given rise to the term acne punctata. They 
usually exist in great numbers, scattered over various 
parts of the face; their most common seat is upon the fore- 
head. Acne papulosa is the least-developed variety of the 
disease. 

Acne Pustulosa. — This is the typical variety. It may 
occur in all degrees of development, from small, pin-head 
to large, split-pea sized pustules. All acne tends to assume 
this form. The amount of suppuration varies; it may be 
slight or abundant. The pustules, as a rule, form rapidly, 
and terminate either in discharge of their contents or in 
reabsorption and desiccation. In shape they are acumi- 
nated, and are surrounded by a deep, circumscribed, more 
or less extensive inflammatory product. According to the 
amount of this peripheral inflammation will the pustule 
have an insignificant or hard base ; when it exists in a 
marked degree the condition is known as acne indurata. 
The terms acne atrophica and acne hypertrophica have 
been applied to designate the results of acne in certain 
cases; the process in the first instance being followed by 
marked atrophy about the ducts of the glands, in the form 



260 EXUDATIONS. 

of pit-like depressions, and in the latter by connective-tissue 
hypertrophy about the glands. 

Acne Artificialis. — Under this head it is in place to 
speak of several kinds of disease which are produced by 
medicinal substances, either taken internally or applied ex- 
ternally. These agents give rise, in certain individuals, to 
an inflammatory condition of the glands, similar to ordinary 
acne. 

In some persons tar, used externally, at times causes an 
inflammation of the sebaceous glands, which continues so 
long as the skin is exposed to its influence. It is frequently 
observed upon those who work in tar. It is characterized 
by a black point, a deposit of tar, in the centre of the pus- 
tule. With this condition there exists more or less general 
inflammation of the whole skin, indicating a deleterious 
effect upon all the cutaneous tissues. 

The preparations of iodine and bromine, taken internally, 
are frequently productive of extensive glandular suppura- 
tion. The more saturated the system with either of these 
substances the more apt is the trouble to show itself. The 
eruption at times is of the most serious nature, resulting in 
the complete involvement and destruction of the sebaceous 
structures. Superficial abscesses occur, and render a tem- 
porary suspension of the medicine imperative, when the 
symptoms are observed to disappear rapidly. Arsenic acts 
usefully in these cases of extreme susceptibility, preventing, 
in a great measure, the occurrence of this form of acne.* 

Etiology. — The causes which may give rise to acne are 
numerous, and are very different in their nature. The 
disorder may be occasioned by agencies operating directly 
upon the skin, or, as is much more frequently the case, by 
causes remote from the seat of the disease. Before men- 
tioning these it is in place to refer to certain facts which 
observation has furnished. 

Acne is seen in both sexes, in about the same proportion. 
It is more common in individuals who have light complex- 

* My friend Dr. S. Weir Mitchell informs me that the bromide and iodide 
eruptions are almost completely controlled by arsenic. 



ACNE. 261 

ions than in those who have dark skins. The most frequent 
and ordinary origin of acne is puberty. The affection first 
shows itself at this time of life, and is apt to continue until 
the system has reassumed a condition of repose. It is at 
this period that the sebaceous glands everywhere are un- 
usually active; the hairs also now begin to develop, and 
necessarily determine increased cell growth about the folli- 
cles. The whole sebaceous system undergoes a great physi- 
ological change, which may occur quietly without occasion- 
ing disorder, or, as is very frequently the case, it may be of 
so violent a character as to give rise to any of the several 
functional troubles of the glands, and notably acne. 

Among the causes which not infrequently are observed to 
be productive of the affection, general debility of the system 
occupies a conspicuous place. Under this head may be 
grouped all those abnormal conditions arising from imper- 
fect physical development, improper nutrition, and other 
defects of the economy, whether organic or functional. The 
disease occurring from such causes is usually of the pustular 
variety, and is apt to show itself copiously. It has been very 
properly called cachectic acne. In this connection anaemia 
and chlorosis may also be mentioned as causes, both of these 
conditions favoring the development of functional disease of 
the sebaceous system. 

One of the most common causes of acne, I feel no hesita- 
tion in stating, is to be found in habitual derangement of the 
alimentary canal. Experience with a large number of cases 
teaches this in most emphatic language. Disorders of the 
stomach and bowels, including dyspepsia and constipation, 
are to be considered as among the most frequent and potent 
causes of the disease. In some cases, even slight derange- 
ment of the bowels is sufficient to cause the acne, which 
will be observed to become better or worse as the condition 
of the bowel is improved or neglected. 

Uterine disorders, particularly those of a functional char- 
acter, are also to be viewed as the origin and direct cause 
of many cases of acne. Cases there are, also, in which it 
is extremely difficult, if not impossible, to find the cause 
of the disease, the patient appearing to be otherwise in a 



262 EXUDATIONS. 

perfect state of health. Such instances, as is well known, 
are not uncommon. 

In addition to the causes enumerated, acne may result, as 
already stated, from the internal use of certain medicinal 
substances. Iodine and bromine are both very frequently 
the cause of an acne-form eruption, which differs but slightly 
from ordinary acne. Among external agencies, tar and its 
preparations are at times causes of an acne-form inflamma- 
tory condition of the glands and surrounding skin. 

Pathology. — Concerning the anatomical nature of acne there 
can be no question. The process originates and has its seat 
in the sebaceous glands and follicles of the skin. It is an 
inflammatory disease, involving the gland structure and the 
tissue surrounding it. 

The process for each individual papule or pustule is for 
the most part an acute one, running a definite course and 
terminating either in reabsorption or in suppuration. The 
first stage in the formation of the acne pustule consists in a 
retention of the secretion. This is soon followed by hyper- 
emia and exudation about the gland, and especially in its 
walls. The connective tissue about the gland now becomes 
infiltrated with cells and takes on active inflammation, which 
sooner or later results in suppuration. 

The disease centres itself around the follicle, where the 
inflammatory product usually resolves itself into pus, forming 
the typical acne pustule, which when fully mature is either 
ruptured and escapes or is retained and reabsorbed. The 
intensity of the exudation varies; if very active, both the 
gland and the follicle may perish, leaving ultimately a de- 
pressed cicatrix to mark the place of the disease. The amount 
of inflammation present determines the two varieties of acne 
described, as well as, at times, certain other accompanying 
anatomical peculiarities, such as induration and hypertrophy. 

Diagnosis. — The chief characters and the history of acne 
are so well defined, in the vast majority of cases, as to occa- 
sion no trouble in diagnosis. The age of the patient, the 
locality attacked and the anatomical seat of the complaint, 
its chronic course, the fact of the lesions appearing and dis- 
appearing within a short period, together with their inflam- 



ACNE. 263 

matory nature, are points to be borne in mind in doubtful 
cases. 

Difficulty may arise in the recognition of artificial acne. 
That caused by tar, may be known by the presence of this 
substance about the patient, which may be detected by its 
peculiar odor. A black point, consisting of tar, may usually 
be observed at the openings of the follicles. 

The acne of iodine and bromine is highly inflammatory ; 
is seen upon all parts of the body; and is generally exten- 
sive and virulent, partaking of the nature of abscess. The 
bromine acne especially is characterized by large areas of 
inflammation, which at times break down into sebaceous 
abscesses and become covered with yellowish crusts. 

Acne often bears a close resemblance to the papular and 
pustular syphiloderms, from which it must be distinguished 
by its history, the absence of the various signs of general 
syphilis usually accompanying the syphilodermata, its course, 
and other peculiarities. Acne is usually scattered quite uni- 
formly over the region attacked; the lesions of syphilis 
tend to group. Acne occurring upon the forehead alone 
occasionally requires careful study to distinguish it from 
syphilis. Severe cases of acne may at times resemble variola 
in appearance, although error in diagnosis can scarcely occur. 

Treatment. — This may very properly be considered under 
two heads, constitutional and local, both of which forms of 
treatment will be found to be of service; they should, in the 
majority of cases, be employed conjointlj\ With all the 
means at our command the disease often proves very rebel- 
lious, and demands every assistance which it is possible to 
afford. At the same time, the disorder is, in my opinion, by 
no means so obstinate as is commonly supposed. 

Constitutional Tkeatment. — Before entering upon active 
treatment it is necessary that the physician make himself 
thoroughly familiar with the constitution and habits of his 
patient. It is impossible to treat severe cases of acne satis- 
factorily without a clear understanding of the causes which 
are at work in producing the disorder. It must be remem- 
bered that it is a functional affection, and that therapeutics 
must be directed against the cause rather than against the 






264 EXUDATIONS. 

individual papules or pustules, for these tend to disappear 
spontaneously. It should be the aim of the physician to 
prevent the disease from appearing. It is on this account 
that internal treatment is very often found to be of much 
greater value in effectually disposing of the disease than 
external applications. If a case be watched in its course 
through a period of months, it will be observed how closely 
the acne follows the general condition of the health, and how 
it is better and worse according to the state of the patient's 
health. 

Various causes will be found to occasion acne. It must, 
however, be borne in mind that the same cause, even if 
present, will not be productive of the disease in every indi- 
vidual. Troubles of one kind or another of the alimentary 
canal are to be inquired after. Dyspepsia, in all its forms, 
may be mentioned as one of the most prolific sources of 
acne ; under this term are to be included irregularity of the 
bowels, constipation, flatulence, acidity, coated tongue, and 
other similar symptoms. Too much attention cannot be 
directed to the functions of the stomach and bowels, for 
derangement of these organs will be found to be at the 
bottom of a vast number of cases. To correct these troubles 
is often extremely difficult, requiring all possible skill. It 
is in these cases that an accurate and thorough knowledge 
of general medicine, together with complete familiarity with 
the action of drugs, proves invaluable to the physician. 

If constipation exist, a free use of either saline or vegeta- 
ble laxatives should be prescribed, in sufficient quantity to 
open the bowels once or twice in the day. Where there is a 
furred tongue, and trouble in the stomach as well as in the 
bowel, I have repeatedly obtained excellent results from an 
acid aperient mixture containing the following: 

R Magnesii Sulphatis, ^iss; 

Ferri Sulphatis, gr. xvi ; 

Acidi Sulphuriei dil., f^ii ; 

Aquse, q. s. ad f^viii. 
M. — Sig. Tablespoonful in a 
gobletful of water as directed. 

This preparation should be taken once a day, preferably a 



ACNE. 265 

half-hour before breakfast. In some cases it is advisable to 
prescribe it twice daily, before breakfast and before supper. 
Where a vegetable bitter is desired, infusion of quassia or 
of calumba may be employed in the place of water. The 
natural mineral waters are also valuable, and may be ordered 
to counteract the condition just referred to. The Saratoga 
waters, particularly the Hathorn and Geyser springs, as well 
as the German Friedrichshall water, a more powerful ca- 
thartic, will be found desirable and efficient; they should be 
taken before meals. Together with these saline laxatives, 
it is often of advantage to direct some one of the ferruginous 
preparations, in small doses, as, for example, the tincture of 
the chloride of iron. If, for any reason, vegetable cathartics 
are preferred, pills containing aloes and rhubarb are the 
most useful. 

Both iron and cod-liver oil are frequently called for, and 
are especially serviceable in the acne of young persons who 
appear ill developed, spare, pale, and but half nourished. 
In these cases the affection is sluggish and non-inflamma- 
tory, and is, in fact, a mixture of acne and comedones. The 
use of these remedies must be continued for some time. In 
females where there is menstrual difficulty the same general 
plan of treatment is to be pursued. The mineral acids are 
also of value in bringing up the general health, and may at 
times be prescribed with advantage. Arsenic is of decided 
service in certain forms of the disease; it may be ordered 
with benefit in the papular variety and in those cases 
where the lesions are imperfectly developed. It should be 
prescribed as a tonic, in one, two, or three minim doses. 
Gubler, of Paris, speaks highly of the use of glycerine in 
the punctate form of acne, administered internally, in table- 
spoonful doses, two or three times daily. Dr. Bulkley in- 
forms me that he has also employed this remedy very 
successfully in cases exhibiting the punctated and indurated 
forms of the disorder. 

Hygiene is of great importance in all cases, but especially 
so in those cases where iron and cod-liver oil are prescribed. 
Proper and sufficient exercise must be insisted upon. A 
daily walk of an hour in the sun should be urged upon the 



266 EXUDATIONS. 

patient. Where it is not contraindicated, a cold bath in the 
morning will be of the greatest assistance in regulating the 
functions of the economy. 

The diet should always be directed by the physician. All 
kinds of heavy or indigestible food, cheese, pastry, pickles, 
spices, should be interdicted; stimulating drinks should also 
be prohibited. 

Local Treatment. — This may now be considered. There 
are two diverse kinds of external treatment which, according 
to the indications in the case under consideration, may be 
adopted. The one method calls for soothing, bland prepara- 
tions, the other for stimulating washes and ointments, with 
a view of arousing the glands to increased activity. 

In rare cases, where there is intense and rapid inflam- 
mation, accompanied with heat and redness and a general 
hyperemia of the skin, mild washes and bland cerates will 
be found to be of most service; the skin here is to be treated 
as any other simple inflammation of a high grade. The 
parts may be washed frequently through the day with cold 
water and castile soap, after which a weak lotion, five 
minims to the ounce, of carbolic acid, glycerine, and water, 
may be applied. 

In the vast majority of cases of acne, however, stimu- 
lating lotions and ointments are demanded, and may be at 
once prescribed with benefit. In acne papulosa, the face 
may be rubbed and washed every evening, before retiring, 
with sapo viridis and water, the application being made with 
a piece of flannel. It will serve to open the gland ducts and 
permit of a subsequent squeezing out of the contents of the 
glands. This may be done between the fingers, or, where 
the papules are small, by means of a watch-key, as described 
in connection with the treatment of comedones. In pustular 
acne, hot water cloths, applied at night, afford relief to the 
congested and swollen follicles, and render their ducts more 
open for the exit of the sebum. This should be followed in 
the morning by a cold douche and frictions. Vapor baths 
and frequent washings of the parts affected are also to be 
recommended. 

Among the more active remedies, sulphur and its prepara- 



ACNE. 267 

tions hold the foremost place. In my opinion they are by far 
the most efficacious remedies in the external treatment of 
acne. Sulphur may be ordered with good result in a large 
number of cases and in various stages of the disease. It 
may be prescribed in the form of ointment or of lotion. 
The strength of the preparation should be made to suit the 
case, varying from a half drachm to two drachms to the 
ounce of ointment. The following can be recommended 
as an eligible formula : 

R Sulphuris Sublimati, ^i ; 

Glycerins, f 51 ; 

Cerati Simplicis, ^i ; 

01. Kosse, gtt. iii. 
M. Ft. ungt. 

Sig. — To be thoroughly rubbed 
into the skin at night. 

I have also found the English hypochloride of sulphur a 
valuable preparation. Sulphur is also employed to advan- 
tage with alcohol, in the proportion of one drachm to four 
ounces; it should be used as a lotion, for ten or fifteen 
minutes, morning and evening. Glycerine, a drachm to the 
ounce, may at times be added with benefit. The following, 
suggested to me by Dr. Bulkley, will be found useful: 

R Sulphuris Loti, 31; 

Etheris, f^iv; 

Alcoholis, fijiiiss. 
M. — Sig. Apply as a lotion. 
Shake the bottle before using. 

Sulphuret of potassium also enjoys a reputation as a local 
remedy ; it may be prescribed as a lotion in the strength of 
ten or twenty grains to the ounce of water. 

"The biniodide of mercury is a useful remedy in those cases 
where active stimulation is required; it is to be ordered as 
an ointment, in the strength of from five to ten grains to 
the ounce. The corrosive chloride of mercury is likewise a 
valuable remedy. It is best prescribed as a lotion, with 
water or alcohol, in the strength of from a quarter or less to 
two grains to the ounce. Emulsion of almonds also consti- 
tutes an excellent vehicle for its employment. The following 
formula is well known : 



268 EXUDATIONS. 

R Hydrargyri Chloridi Corrosivi, gr. i; 

Emuls. Amygdala? Amarae, f^iv ; 

Tinct. Benzoini, f^i. 
M. — Sig. Apply at night. 

The corrosive chloride of mercury constitutes the basis 
of the majority of the "lotions for the toilet'' sold in the 
market. An excellent stimulating remedy is the protiodide 
of mercury, which may be used with good result in cases 
where there is marked induration. It is to be prescribed in 
the form of an ointment, in the strength of from five to 
fifteen grains to the ounce. In severe cases of indurated 
acne, mercurial plaster may be applied with avail, on cloths, 
during the night, as originally suggested by Neumann. 

The various medicated soaps, containing oil of cade, car- 
bolic acid, sulphur, glycerine, are often serviceable in mild 
cases of acne; they may also be made use of with profit in 
conjunction with the remedies enumerated. 

Where the pustules are large and full they should always 
be opened by incision with the knife and their contents 
squeezed out. If there is distention of the superficial cuta- 
neous bloodvessels, they should likewise be incised and 
permitted to discharge. 

The treatment of artificial acne simply requires the re- 
moval of the cause, together with general directions as to 
local remedies, as may be demanded by the case. 

Prognosis. — Experience teaches that cases of acne run ex- 
ceedingly variable courses. The prognosis must depend in 
a great measure upon our being able to determine the cause 
and, at the same time, remove it. In many cases this is pos- 
sible, and the result accordingly favorable. Ou the other 
hand, examples not infrequently occur where the cause is ob- 
scure and inaccessible; these cases are always remarkably 
stubborn. But the question as to result is one of time 
merely, for the disease sooner or later tends to spontaneous 
recovery, although without treatment it may continue for 
years, involving the skin in a very destructive manner. 

In some instances it is a serious process, in that it is 
attended with extensive suppuration and obliteration of the 
glands and ducts, leaving cicatrices which are permanent 



ACNE ROSACEA. 269 

and disfiguring. The scars may be either quite small and 
superficial or they may be large and deep, so pronounced at 
times as to resemble the marks of variola. Their characters 
will depend upon the variety and the intensity of the disease. 
Many cases of acne, on the other hand, leave no scars, sup- 
puration and discharge taking place without destruction of 
the glands. The process may last a long while, often years, 
if left to itself, and finally disappear as the cause has been 
gradually removed by changes in the general health and 
condition of the patient. 

ACNE ROSACEA. 

Syn. Gutta Rosea: Gutta Rosacea; Germ., Kupferrose ; Das Kupfrige 
Gesicht : Fr., Couperose. 

ACNE ROSACEA IS A CHRONIC, HYPER^EMIC OR INFLAMMATORY DIS- 
EASE OF THE FACE, MORE PARTICULARLY THE NOSE, CHARACTERIZED 
BY MARKED REDNESS, DILATATION AND ENLARGEMENT OF THE BLOOD- 
VESSELS, HYPERTROPHY, AND MORE OR LESS ACNE. 

Symptoms. — There are three stages of acne rosacea. The 
disease is characterized at first by a more or less diffuse 
hyperemia in the part, unattended by enlargement or swell- 
ing. The hyperemia is of a passive character, the blood 
circulating slowly through the capillaries, and inclining to 
stasis. If the nose be attacked, it is often seen to be greasy 
(seborrhceic), and is apt to feel cold rather than warm. The 
process is a very gradual one, and comes on slowly, months 
and years being usually necessary for its development. The 
hyperemia is more or less prominent, remaining about the 
part continuously, although subject to variations of degree. 

In the course of time, months or longer, the second stage 
sets in. The redness is noted to be more permanent in 
character, and subject to fewer changes. Upon close ex- 
amination of the affected part, the minute ramifications of 
the cutaneous bloodvessels are noted to be dilated and en- 
larged. They may be seen as delicate, fine, red lines running 
superficially over the skin ; they may be numerous or few. 
The course which these little vessels pursue is noted to be 
irregular; they run in all directions, following, for the most 
part, a crooked, tortuous, or winding course. They vary as 






270 EXUDATIONS. 

to their length; they may be several lines or an inch in 
length. They also vary as to their calibre; they may be 
exceedingly fine and narrow, or coarse and thick. Occur- 
ring upon the alee of the nose, they usually run parallel with 
the cartilages of the alse; over the nose, they run in various 
directions, for the most part irregularly. Sooner or later 
acne papules and pustules manifest themselves over the 
region affected. They appear here or there upon the part, 
and may be few or. numerous; as a rule they occur only in 
limited numbers. Their duration is uncertain; they may 
run their course in a few weeks or less time, or they may 
continue for a much longer period. True acne rosacea is 
now developed, the disease consisting of rosacea, — the dilated 
and hypertrophic bloodvessels, — with papular or pustular 
acne superadded. It occurs in all degrees, from that which 
constitutes but a slight affection to that which greatly dis- 
figures the parts. 

The face is the region attacked. The nose is the common 
seat of the disease ; occurring here, it may involve the alse, 
the tip, or the bridge. The cheeks are also often invaded, 
the disease either first appearing on these regions separately, 
or spreading to them from the nose. The forehead is also 
a not uncommon seat. I have seen it localized here in a 
most positive form, leaving the nose and the rest of the 
face free. Finally, all of the regions enumerated may be 
attacked simultaneously. 

The course of the affection is usually a very chronic one, 
lasting years. In some cases, however, it makes its appear- 
ance quite suddenly, in the course of months; in these in- 
stances there is commonly simple dilatation of the vessels 
only, and not hypertrophy; this latter can take place only 
with time. The affection runs a variable course to its ulti- 
mate termination. The process is rarely, if ever, so violent 
in its nature in women as it is in men. Very often it does 
not go beyond the first stage in women. Having, however, 
in either sex once attained certain degrees of development, 
it may remain in this state ; or, on the other hand, it may 
continue increasing in its proportions, the process becoming 
more violent month by month or year by year, until finally 



ACNE ROSACEA. 271 

the cutaneous tissues are greatly hypertrophied, the blood- 
vessels enormously distended, the glands enlarged, and the 
part seriously altered. This condition constitutes the third 
stage of the process. These changes are usually observed in 
connection with the nose, which organ is not infrequently 
seen to be deformed. The new growth of connective tissue 
and bloodvessels at times goes on to such an extent as to 
give rise to a bulky formation. Noses of this kind, either 
with or without acne, may frequently be seen in the streets 
of our large cities. They are red, usually of a dark-red, livid 
color, and are either simply enlarged, the normal propor- 
tions of the organ being preserved, or are contorted into 
various irregular shapes, more or less lobulated, weighty, 
and pendulous. At times they assume monstrous propor- 
tions, and are as large as a fist (rhinophyma).* 

According as the disease is in one stage or another of its 
development, as well as at one time or another, will the part 
be cold, normal, or hot. In the first stage, that of passive 
hyperemia, the nose is very often cold. Where the process 
is accompanied by the abundant formation of acne lesions, 
the part is apt to be warm, and at times hot; these symp- 
toms come and go from time to time, and may be induced 
by excesses in eating or drinking, as well as by exposure to 
heat and cold. 

Acne rosacea is unattended with pain or itching; the 
subjective symptoms, when these are present at all, consist 
of tinsjlinff and burning sensations. 

Etiology. — The causes are frequently of a diverse nature. 
The disease is met with in both sexes, but the causes may 
be different in the two sexes. It is seen most highly de- 
veloped in men. 

In women the complaint, in the majority of cases, does 
not pass beyond the first stage, — that of hyperemia and 
stasis. In other cases, however, it passes into the second 
stage, and is characterized by permanent enlargement of 



* See a case reported by the author in the Photographic Eeview of Medi- 
cine and Surgery, vol. ii., 1871-2. Also, Hebra's Atlas of Skin Diseases, 
Lieferung vii., Tafel 6. 



272 EXUDATIONS. 

the vessels and more or less deformity. As Hebra first 
pointed out, acne rosacea in women is noted to occur at 
two periods of life, namely, in early womanhood, and again, 
later, at the climacteric period, and is almost invariably 
attended by menstrual disorder. Iir the former of these 
periods the disease is not apt to be severe, and is usually 
observed to be associated with seborrhcea; it is manifestly 
due to the same cause which has brought about this affec- 
tion. With the disappearance of the seborrhcea the rosacea 
also generally departs, either to remain away or to return 
later in life. The causes in these cases are to be found in 
chlorosis, menstrual difficulties of one kind or another, dys- 
peptic troubles, and similar conditions of ill health. At the 
climacteric period, in both married and unmarried women, 
the affection is liable to show itself in an aggravated and 
more permanent form, attended usually with enlargement of 
the bloodvessels. 

In men, occurring early in life, in the first stage, I have not 
infrequently observed it to be associated with a seborrhceic 
condition analogous to that seen in young women. Here, 
however, there is simply hyperemia, the bloodvessels being 
dilated but not permanently enlarged. Noses thus affected 
are almost always cold, notwithstanding their rosy color. 
The causes in these instances are anaemia, general debility, 
nervous prostration, dyspeptic symptoms, and other condi- 
tions which have been mentioned in speaking of seborrhcea. 

Spirituous liquors are known to be a frequent source of 
acne rosacea. Brandy, whiskey, wines, and other strong 
alcoholic drinks, taken in quantity and habitually, give rise 
to the affection in all of its stages, and upon various regions 
of the face. The "brandy nose" and the "wine nose," to 
be seen daily in any community, are common examples of 
the power that alcohol possesses in producing the disease. 

On the other hand, there are cases, occurring in both men 
and women, in which no cause whatever for the development 
of the affection is to be found.* It is at times seen in those 



* See a report of a clinical lecture on Acne Kosacea, by the author, in the 
Medical and Surgical Keporter, Aug. 14, 1875. 



ACNE ROSACEA. 273 

who are constantly exposed to the weather, as cabmen, etc.; 
but in these cases the condition is apt to be one of simple 
rosacea rather than of acne rosacea. 

Pathology. — This has been already alluded to in the con- 
sideration of the symptoms of the disease. There are three 
grades or stages of acne rosacea, and according as one or 
another of these is examined will the changes be somewhat 
different, the difference between the first and the third stage 
being very marked. The process is one involving in the first 
place the bloodvessels of the affected part. In the majority 
of cases this is followed by disturbance and inflammation 
of the sebaceous glands. When the disease is permitted 
to continue, there result dilatation and hypertrophy of the 
bloodvessels of the skin and hypertrophy of the sebaceous 
glands and connective tissue. 

In the first stage there is simply a collection of an undue 
amount of blood in the part, in the form of stasis. This 
condition is apt to remain for an indefinite period — for 
months or for years — without undergoing much alteration. 
Sooner or later, however, the second stage manifests itself 
by permanent dilatation and hypertrophy of the capillaries, 
together with the involvement of the sebaceous glands, in 
the form of acne, either papular or pustular. The disease 
is now typical. It assumes a chronic action, is better and 
worse from time to time, and either remains in this con- 
dition permanently or goes on to the third stage. This is 
characterized by an exaggeration of the second stage, and 
is marked by hypertrophy of all the tissues of the affected 
part, great enlargement of the vessels and of the sebaceous 
glands and their ducts, and connective-tissue new growth, 
which may be so extensive as to produce serious deformity of 
the part attacked. The tissues are now exceedingly vascular. 
The nose at times becomes greatly distorted, and may assume 
any of the various abnormal shapes already referred to. 

Diagnosis. — No difficulty should arise in recognizing the 
affection under consideration when the history, course, and 
peculiar anatomical changes of the disease are borne in 
mind. It is a chronic disease, lasting usually years, and 
often undergoing but little alteration from year to year. In 

18 



274 EXUDATIONS. 

this respect it differs greatly from the tubercular syphiloderm, 
the disease with which it is most apt to be confounded. 
The course of the tubercular syphiloderm may be slow, at 
times continuing through a period of months; acne rosacea, 
when pronounced, will in all probability have existed for 
years. In syphilis the tubercles or lesions do not involve 
the glands: in acne rosacea the seat of the pustules is al- 
ways about the sebaceous glands. Ulceration, in one form 
or another, may usually be detected about syphilis of the 
nose ; this process never takes place in acne rosacea. Crusts 
are apt to be present in syphilis; they never occur in acne 
rosacea. The tubercles of syphilis are generally much 
larger, firmer, and more pronounced than the lesions met 
with in acne rosacea. The color of syphilitic tubercles is a 
dull, coppery red; in acne rosacea the color is either bright 
red or violaceous, according to the stage and form of the 
disease. In acne rosacea the superficial bloodvessels of the 
skin are enlarged and very conspicuous; these features are 
wanting in syphilis. Acne rosacea usually attacks the end 
of the nose uniformly, both sides being involved ; syphilis is 
apt to localize itself more markedly on one side than on the 
other. The severer forms of acne rosacea, such as would be 
likely to be confounded with syphilis, are rarely encountered 
before the age of forty or fifty, and occur more particularly 
in men ; syphilitic disease of this character may show itself 
early in life. Finally, the history will, in doubtful cases, 
usually be of service in arriving at a conclusion. 

Lupus vulgaris may bear some resemblance to acne rosa- 
cea, for, as is well known, this disease is very apt to make 
its appearance about the face, and especially the nose. In 
lupus vulgaris the characteristic, roundish, yellowish or red- 
dish papules and tubercles may always be detected ; they are 
pin-head or larger in size, and usually involve a portion of 
the nose, as the tip or one ala, only. The bloodvessels are 
not enlarged in lupus vulgaris. Ulceration, moreover, fol- 
lowed by crusts and ugly cicatrices, takes place sooner or 
later in lupus vulgaris ; these symptoms are never present 
in acne rosacea. 

Lupus erythematosus can only be confounded with acne 



ACNE ROSACEA. 275 

rosacea when it happens to show itself upon the end of the 
nose. The surface of the skin in lupus erythematosus is 
rough, harsh, and covered with line, tenacious, } T ellowish 
scales, which are seen to be connected with the openings 
of the sebaceous follicles; in acne rosacea none of these 
symptoms are present. 

The first stage of acne rosacea, especially of the nose, 
bears considerable resemblance to frost-bite. The histories 
of the two affections, however, are very different, acne rosa- 
cea making its appearance slowly, while frost-bite shows 
itself suddenly. The symptoms, moreover, will always serve 
to distinguish these diseases. In frost-bite the nose is apt to 
be swollen and more or less shining, is of a bluish-red color, 
and is the seat of a tingling sensation ; in this stage of acne 
rosacea the nose is not swolleu, is usually of a bright red 
color and more or less seborrhoeic. 

Acne rosacea may be known from acne by the presence 
of the enlarged bloodvessels, and the hyperemia of the part 
affected. The line dividing the early stage of acne rosacea 
from certain forms of acne is at times indistinct, for, as we 
have seen, the disease under consideration is made up of 
certain changes of the vascular system, together with acne. 
The involvement of the bloodvessels will always determine 
the case to be one of acne rosacea. 

Treatment. — The mode of treatment to be adopted will 
depend upon the stage of the disease which presents itself, 
and upon the nature of the cause of the affection, where this 
is ascertainable. 

Both constitutional and local remedies are employed. The 
causes which have given rise to the process should be dili- 
gently sought after, and, where detected, should be removed 
if possible. In females, uterine and menstrual disorders, and 
bowel derangement, are to be corrected by the appropriate 
remedies ; the general health is to be improved by the prepa- 
rations of iron, and the bowels regulated by aloes and the 
natural mineral waters. In males, the use of all alcoholic 
drink is to be interdicted. The bowels are to be kept open 
by saline laxatives. The diet in both sexes should be pre- 
scribed as in the case of acne. 



276 EXUDATIONS. 

Local treatment, however, is, in the vast majority of cases, 
found to be of much greater value than internal remedies. 
The remedies to be employed vary with the stage of the dis- 
ease. Stimulating preparations of one kind or another are, 
however, suitable in all stages. In the first stage we may 
expect good results from the use of sulphur and the cor- 
rosive chloride of mercury. The former of these remedies 
I have found the most valuable. It may be employed in 
the form of an ointment or as a lotion, as in the case of 
acne. From one to three drachms of sublimed sulphur 
(the strength being made to suit the susceptibility of the 
skin in the case under treatment) to the ounce of simple 
ointment will be found serviceable in the majority of cases. 
The English hypochloride of sulphur may also be used in 
the same strength, as recommended by Wilson. Anderson 
gives the formula for a preparation composed of the hypo- 
chloride of sulphur with rumex ointment,* two drachms to 
the ounce, which he speaks well of. Lotions, containing sul- 
phur, are often of great service; in some cases I have found 
them to be more useful than ointments. They may be pre- 
pared according to the formulae given in speaking of acne. 
The corrosive chloride of mercury may also be employed in 
the first stage of acne rosacea with favorable result, in the 
strength of from a quarter grain to two grains to the ounce, 
either of ointment or of fluid, as alcohol. Likewise the 
various officinal mercurial ointments, care being taken not 
to make them too strong at first. Mercurial plaster, spread 
upon cloths and applied to the part, may be used in certain 
cases with benefit, as recommended by Neumann and Hebra. 

In the second stage of the disease stronger applications 
are frequently required. The distended bloodvessels here 
should in the first place be incised with a sharp knife, and 
permitted to bleed. Cold water cloths, or the tincture of 
the chloride of iron, may afterwards be applied to arrest 

* The rumex ointment is prepared as follows: Bumex root, nine ounces; 
lard, six ounces; yellow wax, one ounce; water, sufficient quantity. Wash 
and bruise the roots ; boil for two hours and strain ; evaporate to four ounces ; 
add gradually to the wax and lard previously melted, and keep stirring until 
cold. 



SYCOSIS NON-PARASITICA. 277 

any excessive bleeding that may occur. This operation is 
to be repeated once or twice weekly, according to circum- 
stances, a small portion only of the disease being attacked 
in this manner at each sitting. Subsequently one of the 
sulphur ointments may be rubbed into the part. 

In the second stage I have also used caustic potassa solu- 
tions with good result, in the strength of from five to ten or 
more grains to the ounce, painted with a brush over the part 
once or twice weekly, followed by an emollient ointment. 

Faradization has recently been employed by Cheadle, of 
London, who reports favorable results in several cases.* 

Where the process has been allowed to go on to the third 
stage, — when the nose is greatly deformed by hypertrophy 
and extensive connective-tissue new formation, — ablation of 
the diseased skin with the knife is the only effectual remedy, 
although much can be done to modify the condition by 
means of the remedies already referred to. 

Prognosis. — From what has been said it will be seen that 
the prognosis must depend upon the stage in which the dis- 
ease exists. Where the process has not passed beyond the 
first stage, a favorable result may usually be looked for; on 
the other hand, where a uew growth of connective tissue has 
taken place about the vessels and around the glands, the 
prognosis should be extremely guarded. Much, however, 
can be accomplished by judicious treatment, which in all 
cases will prove of more or less service. Left to itself, the 
disease exhibits no disposition to spontaneous cure, but, on 
the contrary, inclines to continue for years, altering the tis- 
sues of the part attacked in the manner already indicated. 

SYCOSIS NON-PARASITICA. 

Syn. Mentagra; Sycosis; Acne Mentagra ; Germ., Bartfinne; .Fr., Sycosis 
Non-Parasitaire. 

Sycosis non- parasitica is a chronic, inflammatory, non-con- 
tagious DISEASE, INVOLVING THE HAIR FOLLICLES OF THE FACE, 
CHARACTERIZED BY PUSTULES, PAPULES, AND TUBERCLES, ACCOM- 
PANIED WITH MORE OR LESS SWELLING AND BURNING SENSATIONS. 

Symptoms. — The disease ordinarily commences by the for- 

* The Practitioner, July, 1874. 



278 EXUDATIONS. 

mation of several or numbers of pustules around the hairs 
situated about the region of the cheek, chin, or upper lip. 
New lesions develop, until in a short time a patch involving 
considerable surface results. The pustules are seen to have 
their seat immediately around hairs; they are acuminated, 
pin-head or split-pea sized; contain a thick, yellow fluid, and 
show no disposition to immediate rupture. They are usually 
discrete, and remain so throughout their course. Not in- 
frequently, however, they are so numerous as to be greatly 
crowded and in contact with one another. They are accom- 
panied by redness of the surrounding skin, swelling, and 
sensations which are described as being of a burning char- 
acter. If the beard be permitted to remain, the pustules 
may break and pour forth their contents, which dry into 
crusts ; when this takes place the part may become com- 
pletely encrusted. 

The cheeks, chin, and upper lip are the common seats of 
the disease; any one of these regions alone, or all of them 
at the same time, may be attacked. The hairy portion of 
the neck, in cases where the disease is diffused, may also 
be involved. The affection may begin either by showing 
itself at once over all the parts, or, as is more usually the 
case, it may attack one portion and thence extend over 
other regions. The hairs are observed to be healthy, and 
are usually so firmly seated in their follicles as to render 
their extraction painful; they are neither twisted, brittle, nor 
broken off. The course of the disease is exceedingly chronic. 
Without proper treatment it is apt to continue for years. 

Etiology. — The causes are not well understood. The dis- 
ease usually occurs between the ages of twenty-five and 
fifty. It is encountered among all classes of society, and 
attacks the well-nourished as well as those surrounded by 
poverty. It is met with among those who do not shave, as 
well as among those who do; shaving, therefore, cannot be 
regarded as its cause. 

It is not contagious. 

Pathology. — Non-parasitic sycosis is to be viewed as a 
simple inflammation of the hair follicle. The inflamma- 
tion extends along the whole course of the follicle, and also 



SYCOSIS NON-PARASITICA. 279 

involves the adjacent tissues, terminating in resorption or 
in suppuration. The amount of pus formation varies; it 
is, however, usually extensive, and constitutes a prominent 
symptom. The hairs are firmly seated in their follicles, not- 
withstanding the presence of abundant pus, and can only be 
extracted with difficulty and pain. Their roots are seen to 
be somewhat enlarged, luxuriant, and covered with, a light 
yellowish, jelly-like product, which is to be viewed as plastic 
material, the result of inflammatory action. Later in the 
course of the disease the hairs may become loose from ex- 
cessive and long-continued suppuration, in which case the 
follicles are destroyed. 

Diagnosis. — Non-parasitic sycosis is to be distinguished 
from parasitic sycosis, from which it differs not only in its 
cause, but also in its clinical features. These two diseases 
both attack the hair follicle with inflammation, but produce 
such different symptoms as to call for a clear separation. 

The peculiar lumpy, tubercular, nodular, uneven surface 
of the skin, so characteristic of parasitic sycosis, is alto- 
gether wanting in the disease under discussion. But the 
changes connected with the hair itself will be found of even 
more value than this symptom, and may be relied upon as 
a means of diagnosis. In parasitic sycosis they are loose, 
readily extracted from their follicles, and are seen to be 
twisted or broken, with a root that is often dry and mani- 
festly diseased. Under the microscope the question of diag- 
nosis offers no difficulty, for the presence or absence of 
fungus is easily demonstrable. 

It often bears a likeness to eczema, from which, however, 
it may be known by the absence of oozing, as well as of 
itching ; eczema, moreover, attacking the beard, would be 
apt to be present upon other portions of the face. It will 
also be remembered that in sycosis each pustule is pene- 
trated through its centre by a hair. 

No difficulty will be experienced in distinguishing sycosis 
from the acuminated pustular syphiloderm, which is apt to 
attack the face; the existence of pustules upon other re- 
gions of the face, as well as upon the body, would be suffi- 
cient to exclude sycosis. 



280 EXUDATIONS. 

Treatment. — External treatment will be found of greater 
value than internal remedies. In extremely obstinate cases, 
however, as well as in those which seem to be associated 
with a general impairment of nutrition, iron, small doses 
of arsenic, and cod-liver oil may be given with advantage. 
Where there is considerable inflammatory thickening, Fox 
speaks well of Donovan's solution. In some cases benefit 
is to be derived from the judicious use of saline aperients. 
The general condition is to be looked after in all cases, as 
in other diseases of an inflammatory character. 

The first and one of the most important steps in the 
local treatment is to have the parts shaved. This is to be 
performed every day or every other day, according to the 
rapidity with which the beard grows. The hairs should at 
first be clipped with scissors, after which they may be mace- 
rated with poultice; when this has been accomplished, no 
great pain will be experienced upon shaving. After a few 
days the operation will be found very much less painful, 
and in a short time may be performed without serious dis- 
comfort. 

The applications now to be employed must vary with the 
stage of the disease, whether acute or chronic, and with any 
peculiarity of the skin that may exist. If very inflammatory, 
black wash may be applied several times through the day, 
followed by oxide of zinc ointment with a drachm of cam- 
phor to the ounce, spread upon cloths and bound firmly to 
the part. A weak calomel ointment, half a drachm to the 
ounce, may also be rubbed into the skin with benefit. 

In cases where the affection has existed for some time, 
the part may be treated by means of diachylon ointment 
and soft soap. The pustules are to be opened, and the skin 
well rubbed with soft soap and water, after which strips of 
muslin spread quite thick with diachylon ointment are to 
be applied, and bound to the face by means of a bandage. 
This proceeding is to be repeated twice daily, together with 
the process of shaving once a day. 

In other cases, a more stimulating plan of treatment may 
be used with advantage; for this purpose weak sulphur oint- 
ment, half a drachm to the ounce, or ammoniated mercury, 



IMPETIGO. 281 

in the form of ointment, in the same strength, will be found of 
service. The ointment of the nitrate of mercury, a drachm 
to the ounce of simple oiutment, may also be employed with 
good result; likewise the red oxide of mercury, in moderate 
strength, from five to fifteen grains to the ounce. Corrosive 
chloride of mercury in the form of a lotion, from a quarter 
to a grain to the ounce of water or alcohol, may also be used 
in certain cases with benefit. 

Epilation is recommended strongly by Hebra and others, 
the hairs, one at a time, being extracted by means of a pair 
of epilating forceps. A small area is epilated each day, and 
the part after the operation dressed with diachylon or oxide 
of zinc ointment. The operation is painful, and, according 
to my experience, cau be tolerated only in those cases where 
there exists considerable suppuration. 

Veil], of Cannstadt, treats the disease according to the 
following method. The hairs are cut short, the crusts re- 
moved with poultice, and a preparation consisting of two 
parts of tar and one part of sapo viridis is rubbed into the 
skin, after which the hairs may be readily extracted. After 
epilation has been performed, acetic acid is applied with a 
brush. A crust is formed, which comes off in three or four 
days; the operation, if necessary, is to be repeated. Sul- 
phur ointment completes the treatment, recovery usually 
taking place in four weeks. 

The patient in all cases of sycosis should be directed to 
continue shaving for months after all disease has disap- 
peared, in order to avoid the risk of a relapse. 

Prognosis. — The hope of a speedy cure should never be 
held out to the patient, for, while certain cases yield quite 
readily to treatment, others, and perhaps the majority, will 
be found to resist the most judicious remedies. 

IMPETIGO. 

Impetigo is an acute, exudative disease, characterized by 
one or more pea or finger-nail sized, discrete, rounded and 
elevated, firm pustules, unattended by itching, occurring 
for the most part in children. 

Symptoms. — The eruption may or may not be preceded by 



282 EXUDATIONS. 

symptoms of general disturbance. They are never marked; 
when present, they consist of loss of appetite, constipation, 
malaise, and restlessness at night, for a day or two before the 
cutaneous disease appears. This latter manifests itself by 
the formation of one or more distinct pustules. They make 
their appearance quite suddenly, in the course of from twelve 
to twenty-four hours. They begin as veritable pustules, the 
pustular character of the lesion showing itself in the ear- 
liest stage of the process. When fully formed, the pustules 
vary in size from a split pea to a finger-nail. They are 
round or oval in shape; are raised prominently above the 
surrounding skin ; and are at first surrounded with a more 
or less pronounced areola, which subsequently fades. The 
elevation is striking, varying from an eighth to a half of an 
inch, and gives the lesions a dome-shaped or semiglobular 
outline. There is no central depression or umbilicus. Iu 
color the pustules are yellow; at times they are whitish. 
They are usually tensely distended with fluid, and are con- 
sequently conspicuous. After the pustules have arrived at 
maturity, the areola referred to subsides, and leaves the pus- 
tules clearly defined. There is but little infiltration present. 
The walls of the pustules are thick, and are seen to be made 
up of the whole epidermis. Throughout their course they 
manifest no disposition to rupture. They are discrete, and 
occur here and there in an isolated manner. Even when 
situated close together, as often occurs upon the hands, they 
do not incline to coalesce. In number they vary from several 
to a dozen or more. 

They occur upon all parts of the body, but are commonly 
seen about the face, hands and fingers, feet and toes, and 
lower extremities. I have also encountered them upon the 
palms and soles. They are not attended, as a rule, by either 
itching or burning; soreness, however, is very often com- 
plaiued of. 

The disease runs an acute course, usually from one to two 
weeks in duration. The pustules appear suddenly, often in 
a half-day's time, and are apt to come out one after another 
during the first three or four days of the attack. Having 
reached their full size, they remain in this condition for a 



IMPETIGO. 283 

day or two, when their contents become altered, at times 
bloody, and they undergo reabsorption or crusting. Very 
frequently they are ruptured through contact with external 
objects, rubbing of the clothing or scratching, when they 
are observed to pour out a thin puriform fluid; as a rule, 
it is not thick, as might be looked for from the appearance 
of the pustules, nor is it usually abundant. If ruptured or 
pricked with a needle early in their course, they again fill 
with fluid. The amount of crusting varies : at times it takes 
place abundantly, yielding yellowish or brownish crusts; in 
other cases it is insignificant, the fluid undergoing reabsorp- 
tion. Whatever crust remains rapidly desiccates and drops 
off, leaving a slightly red base without pigmentation or scar. 
The disease is a benign process, inclining to terminate in 
speedy recovery, either with or without treatment. Relapses 
are not apt to occur.* 

Etiology. — Its causes are involved in obscurity. It is an 
affection confined for the most part to children, and is usually 
encountered between the ages of three and eight. As a rule, 
it occurs in stout, well-nourished, and healthy subjects, who 
perhaps have had little or no previous illness. It does not 
appear to be in any way connected with eczema. It is not 
apt to be associated with disorder of the stomach or of the 
bowels. It is not contagious. 

Pathology. — The lesion is a typical pustule. The first 
manifestation seen upon the skin possesses all of the char- 
acters of a true pustule, which continue throughout the 
entire course of the disease. The process is a circumscribed 
one, as is shown by the absence of a permanent areola. At 
no time during its course are the lesions seated upon a 
highly in flammatory base ; they rise abruptly from the sur- 
face very much in the manner of the bullae of pemphigus. 
Anatomically the pustule is well formed, and possesses re- 
markably thick walls, which are composed of both the horny 
and the mucous layers of the epidermis. Microscopical 



* The disease I have described is, it seems to me, the only affection to which 
it is proper to apply the term Impetigo. The process is a distinct and well- 
marked one, and is worthy of this name. 






284 EXUDATIONS. 

examinations of the contents of the pustules, which I have 
made in various stages of the process, show the fluid to be of 
a whitish-yellow color, the color as well as the consistence 
of the fluid depending somewhat upon the age of the lesion. 
Under two hundred and fifty diameters the field was seen to 
contain a variable number of pus corpuscles, more or less 
closely packed together. Here and there were red blood 
corpuscles, epithelial cells, and cellular detritus. 

Diagnosis. — The disease has, I think, features sufficiently 
distinctive to allow of its being separated from other affec- 
tions to which it bears resemblance. It may be distinguished 
from pustular eczema by the unexpected appearance and 
rapid development of the lesions. The size and peculiar 
conformation of the pustules are also different from those of 
eczema. The pustules of impetigo are large and prominent ; 
those of eczema are small, and are not raised to the same 
extent. In impetigo the pustules are discrete, and do not 
incline to run together; in eczema they are usually seated 
close together, and manifest a disposition to coalesce. The 
pustules of impetigo rarely occur in numbers; those of 
eczema are usually numerous. In impetigo there is little 
infiltration and no marked thickening of the tissues ; in 
eczema infiltration and more or less thickening of the skin 
are pathognomonic features. 

In impetigo the pustules do not incline to rupture, and 
there is consequently no discharge; in eczema the pustules 
rupture early in their course, and are succeeded by extensive 
crusting; the exudation, moreover, is in these cases apt to 
continue. In impetigo there is little or no itching; in 
eczema there is always more or less itching. 

Impetigo bears a close resemblance, both in its general 
features and in its course, to impetigo contagiosa, which is to 
be viewed not as a variety of impetigo, but as a distinct dis- 
ease. The initial lesion in impetigo contagiosa is a vesico- 
pustule, similar to that of vaccinia ; in impetigo it is a perfect 
pustule. The lesion of impetigo contagiosa is quite super- 
ficial; that of impetigo has a deeper seat. The pustule of 
impetigo contagiosa is flat, and is often marked by umbilica- 
tion ; that of impetigo is rounded, conspicuously raised, and 



IMPETIGO CONTAGIOSA. 285 

je without central depression. The crusts of impetigo con- 
tagiosa are straw-colored, and are characteristic; those of 
impetigo are yellowish or brownish. Impetigo, moreover, 
is not contagious. 

Impetigo also resembles ecthyma. In ecthyma the pus- 
tules are flat, and are surrounded by an extensive, inflamma- 
tory, hard base; in impetigo they are elevated and rounded, 
and have but a slight areola. The crusts in these diseases 
are also very different; in ecthyma they are brownish or 
blackish in color, are large and flat, and are seated upon a 
deep excoriation. Impetigo usually occurs in strong, healthy 
children; ecthyma in the weakly and cachectic. 

Treatment. — In the majority of cases but little interference 
is necessary. The pustules, as soon as they mature, may be 
opened with a sharp bistoury and the contents permitted to 
escape. The part should be protected from external influ- 
ences, as rubbing of the clothes or other violence. The 
pustules may be dressed with some mildly stimulating oint- 
ment, as in the case of impetigo contagiosa. The affection 
inclines to spontaneous recovery. 

IMPETIGO CONTAGIOSA. 

Impetigo contagiosa is an acute, inflammatory, contagious 
disease. characterized by the formation of one or more super- 
ficial, flat, discrete, roundish yesico-pustules, the size of a 
split pea or finger-nail, which pass into granular, straw- 
colored crusts. 

Symptoms. — The eruption is usually preceded by slight 
febrile disturbance. Small, isolated, flat vesicles are first 
noticed, which in a day or two become vesico-pustules or 
even pustules. At first they are quite small, but they tend 
to increase in size very rapidly, until they become as large 
as small coins. They are roundish and flat in shape, and are 
very often marked by distinct central umbilication. A slight 
areola usually surrounds them, which, however, disappears 
upon their maturation. They rarely exist in numbers; usually 
only two or three are to be seen at the same time. Xot in- 
frequently, when situated close together, the lesions coalesce 
and form a small patch. In a very few days, either from rap- 



286 EXUDATIONS. 

ture or their natural course, crusts form; these, indeed, are 
almost always present when the case first comes under ob- 
servation. They are noticed to be flat, somewhat elevated 
above the surrounding skin, straw-colored, and but slightly 
adherent. Beneath them exists an excoriation, which secretes 
a puriform fluid. After the crusts have become dry they fall 
off, leaving a reddish base, which gradually fades away. The 
lesions may all show themselves simultaneously, or they may 
appear in successive crops. The usual seat of the eruption 
is about the face; but the scalp and arms, as well as other 
regions of the body, may also be attacked. It may be spread 
by auto-inoculation. Its course is a definite one, lasting 
usually about ten days; rarely longer than two weeks.* 

Etiology. — It is encountered chiefly among the poor and 
improperly cared-for, although it is at times also met with 
among those in the upper walks of life. It is confined 
almost exclusively to children. It is both contagious and 
auto-inoculable. The cause of the disease is not, as yet, 
conclusively determined, although evidence points strongly 
to its being due to a vegetable organism; further proof is, 
however, necessary before this theory can be accepted as 
established. In a large number of instances it is known to 
follow vaccination. f 

Pathology. — The views of observers are somewhat con- 
flicting as to the nature of the disease, some holding that 
it is due to the presence of a vegetable organism, others 
that no such cause can be demonstrated. Both KohnJ and 
Piffard§ describe a fungus as existing in the crusts; the 
growths discovered by these observers, however, are not 
the same. Kohn found a luxuriant parasite, consisting of 
thin, long mycelium, which was branched and fork-shaped, 

* Cases of this affection have been ably described by Dr. K. W. Taylor, of 
New York. See Amer. Jour, of Syph. and Derm., Oct. 1871, p. 368; also 
Boston Med. and Surg. Jour., June 6, 1872. 

f The relationship between contagious impetigo and vaccination is as yet 
not clear, but that some connection does at times exist there can be no doubt. 
The cases which have come under my observation have, with few exceptions, 
followed vaccination. 

$ Wien. Med. Presse, June 4, 1871. 

\ New York Med. Jour., June, 1872. 



IMPETIGO CONTAGIOSA. 287 

each thread terminating in a refractive, knob-like end. It 
made a thick network, here and there assuming the form 
of distinct loops. In general appearance it resembled the 
tricophyton as seen in tinea circinata, but differed from it 
in being not more than half as thick. Here and there it 
was observed to be in a state of fructification. The vege- 
table organism described by Piffard, on the other hand, is 
made up of variously shaped and sized, mostly extremely 
minute, circular, oval, biscuit-shaped, and rod-like struc- 
tures. Neither mycelium nor spores were present.* Other 
observers have not been able to demonstrate its parasitic 
nature. 

Diagnosis. — The affection is most liable to be confounded 
with eczema pustulosum and with impetigo; it may always 
be distinguished from these diseases by the history, char- 
acter, and course of the lesions. The crust is a superficial 
one, and has the appearance, as stated by Fox, of being 
"s.tuck on." The lesions are usually isolated and itch but 
little, in both of which points they differ from those of 
eczema. The pustule of impetigo is prominently raised; 
that of impetigo contagiosa is flat. 

It may also bear a resemblance to varicella. Both affec- 
tions usually show themselves about the face. The vesicles 
and vesico-pustules of varicella, however, are smaller, and 
are not attended with proportionately the same amount of 
crusting, nor are the crusts of the same character as regards 
their color and consistence. The usual distribution of vari- 
cella over various regions of the body will also serve to dis- 
tinguish the diseases." The lesions of varicella are, further- 
more, apt to be much more numerous than those of impetigo 
contagiosa. Finally, symptoms of constitutional disturbance 
are generally present in varicella; they are wanting in im- 
petigo contagiosa. 

* Dr. Piffard in his investigations twice encountered a fungus similar to 
that described by Kohn, but inclines to the view of its being accidental. 

In the July number, 1872, of the N. Y. Med. Jour., Dr. Piffard discusses 
impetigo contagiosa and its relations to vaccinia. A series of microscopic 
examinations upon the crusts of vaccinia were made, in all of which he dis- 
covered the same fungoid bodies found in impetigo contagiosa. 



288 EXUDATIONS. 

Treatment. — The mildest remedies are to be used, for the 
affection tends to both rapid and spontaneous recovery. 
Oxide of zinc ointment, together with cleanliness, will often 
prove sufficient. An ointment composed of live grains of 
ammoniated mercury to the ounce, as recommended by Fox, 
may also be used advantageously. 

Prognosis. — This is always favorable. 

ECTHYMA. 

Ecthyma is characterized by the formation of one or 
more isolated, flat pustules, the size of a finger-nail, 
situated upon a hard, highly inflammatory base, followed 
by a deep excoriation and brownish or blackish crusts. 

The pustules are usually well developed. They may exist 
either singly or in numbers; as many as a dozen are not 
infrequently present. They are roundish or oval in form, 
circumscribed, and exhibit a slightly elevated border. They 
are notably flat, or broad, and consequently never very fully 
distended, their contents being evenly distributed. At first 
they are yellow in color ; later they become somewhat red- 
dish, owing to the admixture of blood. In size they vary 
from a small to a large finger-nail. Immediately around 
their margin the skin is of a bright red or lurid color, form- 
ing an areola of considerable extent; it is also quite hard 
to the touch. After existing for a few days the pustules 
become flaccid, begin to desiccate, and are soon converted 
into large, flat crusts, of a dark brownish color. They are 
not adherent, and may be raised, when an extensive excori- 
ation, covered with a copious, yellowish, sanious secretion, 
will be observed. The destruction of tissue scarcely amounts 
to ulceration; at times, however, where the process has been 
an active one, the excavation is by no means shallow. 

The extremities, especially the legs, the shoulders, and the 
back, are the regions commonly attacked. The lesions have 
an acute course, developing and running their existence in 
a few days; after they have begun to crust the process pro- 
ceeds more slowly, and terminates in about a fortnight by 
the crusts falling off and leaving more or less of a scar. 
The pustules are apt to appear successively during the first 



ECTHYMA. 289 

week, new ones being formed each day, after which time 
they usually cease to appear. Where the cause is kept 
up, however, they may continue to show themselves for an 
indefinite period. 

The affection is ordinarily announced with slight febrile 
disturbance, which tends to subside upon the appearance 
of the eruption. Heat, more or less itching, and a certain 
amount of pain, accompany the pustules; they are usually 
tender to the touch. Ecthyma is encountered upon both 
children and adults; it may occur at any time of life. It 
almost invariably manifests itself in those who are poorly 
nourished and improperly cared for. 

Etiology. — The causes of the disease are to be found in all 
those influences which tend to lower the normal tone. It is 
not contagious. The affection is most frequently met with 
in prisons, poor-houses, tenement-houses, and among those 
who live in squalor and abject poverty. It is rarely seen in 
the upper walks of life or in those who are properly cared 
for. Improper and insufficient diet, want of ventilation, 
excessive work, and uncleanliness are all causes which are 
known to call forth the disease. In those predisposed to 
ecthyma, acquired through an existence among the influ- 
ences just mentioned, it may be produced by various ex- 
ternal agencies, among which acari, pediculi, and scratching 
occupy a conspicuous place; these, however, are to be viewed 
as exciting causes. 

Pathology. — The affection is markedly inflammatory in 
character, and tends to the immediate formation of pus. 
The cutaneous disturbance is severe, as shown by the rapid 
development of the lesion, its size, and its hard, sensitively- 
inflamed base. It is a typical pustular process. Commencing 
as a pustule, it tends to assume speedily its definite propor- 
tions, after which it is at once followed by desiccation and 
crusting. The lesion is a superficial one; the excoriation 
does not extend beyond the papillary layer of the corium. 
A slight scar is observed to remain, which, however, is not 
permanent. Pigmentation also exists, which in a few weeks 
or a month likewise passes away. In the colored race com- 
plete absence of pigmentation succeeds the eruption. 

19 



290 EXUDATIONS. 

Diagnosis. — Ecthyma may be confounded with eczema pus- 
tuloeum, impetigo, impetigo contagiosa, and the large, flat- 
pustular syphiloderm. It may be known from eczema by 
the size and form of its pustules, as well as by the fact that 
they always occur isolated. The peculiar, inflammatory, 
hard base, with extended areola, the large, flat pustule, its 
course, the brownish or blackish crust, and the excoriation, 
will, moreover, always serve to distinguish it from eczema. 
It may be known from impetigo by the character of the 
pustule, areola, and crust. 

It differs from impetigo contagiosa in its non-contagious 
nature, the character of the lesion, the color and appearance 
of the crust, the region involved, and the general condition 
of the patient attacked. 

Ecthyma bears a close resemblance to the large, flat-pus- 
tular syphiloderm.* The course of ecthyma, however, is 
very different from that of the syphiloderm ; it develops 
itself more rapidly, and usually terminates in a few weeks. 
There is, moreover, always more heat and pain, together 
with other signs of local disturbance, about ecthyma than 
about syphilis. The characters of the ulcers are sufficient 
to distinguish the two diseases : in ecthyma the ulceration 
is slight and superficial; in syphilis the edges are abrupt 
and more or less deep, and the excavation is covered with a 
thick, yellowish, puriform fluid. The crusts of ecthyma are 
brownish in color; in syphilis they are blackish. In ecthyma 
they are less bulky than in syphilis, and do not tend to heap 
up into layers. If the disease be syphilis, other symptoms 
will almost invariably be present, which will further aid in 
establishing the diagnosis. 

Treatment. — The affection yields readily to the proper 
remedies. All means should be adopted for the purpose of 
reinstating good health. The diet is of great importance; 
it should consist of the most nutritious and wholesome food, 
including meat, eggs, milk, ale, and other articles calculated 
to improve the tone of the system. The hygienic surround- 

* I have found this to be particularly the case in the colored race, where 
the areola and color of the eruption are altogether wanting. 



PSORIASIS. 291 

ings should be inquired into ; cleanliness, frequent bathing, 
fresh air, exercise, proper rest, should all claim attention 
and regulation. It is to be remembered that the affection is 
one caused by debility; very frequently the means just indi- 
cated will be alone sufficient to arrest the process. It is, 
however, proper also to administer tonics, among which the 
preparations of iron, quinine, and the mineral acids, will 
prove of especial value. 

The local treatment will vary with the stage in which 
the lesions exist. During the first week, alkaline baths, six 
ounces of the bicarbonate of sodium to the bath, may be 
ordered ; various cooling lotions may also be employed, as 
in any other inflammatory condition of the skin. After 
crusts have formed, they are to be removed by poultice or 
water dressing, and a mild stimulating ointment applied. 

Be Ungt. Zinci Ox. Benz., 31 ; 

Hydrargyri Amraoniati, gr. x. 
M. ft. unguentum. 

If there is no disposition to recovery, the sores may be 
touched with more stimulating substances, as the nitrate of 
silver, carbolic acid, or solution of chlorinated soda. It is 
scarcely necessary to say that if pediculi or other external 
irritants are present, they should be at once removed. 

Prognosis. — This is always favorable. A few weeks usually 
suffice to restore the patient to health, provided a thorough 
change can be obtaiued and the treatment carried out. Re- 
lapses only occur if the system be allowed to fall again into 
the condition which originally occasioned the disease. 

PSORIASIS. 

Syn. Lepra; Lepra Alphos ; Alphos; Psora; Germ., Psoriasis; Schup- 
penflechte ; Fr., Psoriasis. 

Psoriasis is a chronic disease of the skin, characterized 
by reddish, slightly elevated, dry, rough, inflammatory 
patches, variable as to size, shape, and number, covered 
with abundant whitish or grayish, mother-of-pearl colored, 
imbricated scales. 

Symptoms. — Psoriasis, like other inflammatory diseases of 
the skin, varies greatly as to the extent of its development, 



292 EXUDATIONS. 

in one case showing a well-formed and typical eruption, 
while in another it is very imperfectly and scantily defined. 
As a rule, however, it possesses characters which render it 
one of the most uniform and marked of all the cutaneous 
diseases. It commences by the formation of small reddish 
spots, scarcely raised above the level of the skin, which 
become immediately covered with whitish scales. These 
lesions usually increase rapidly in size, and often in a few 
days develop into patches as large as a coin. The scales 
are present from the beginning, and are seated superficially 
upon the reddened and inflamed skin. The rapidity with 
which the first lesions of psoriasis extend is often remark- 
able, especially when it is considered that the process soon 
settles into a chronic course. It also occurs that the erup- 
tion is sluggish from its commencement, spreading slowly, 
and perhaps involving only a small portion of the body. 
The amount of skin attacked varies exceedingly, the whole 
surface being at times the seat of disease, while in other 
cases but a single small patch exists. 

Psoriasis as it is commonly encountered consists of numer- 
ous detached patches or islands of disease, scattered more or 
less over the body, tending to run a definite, slow existence. 
These distinct patches, with perfectly healthy tissue between 
them, are quite characteristic, their sharp and abrupt out- 
lines causing them to stand out conspicuously. They may 
be either light or dark red, depending upon the amount 
of inflammation, and are invariably covered with whitish 
scales, usually in such quantities as to mask the color of the 
skin beneath. When of any size, the patches are slightly 
raised and have a perceptible border about their periphery ; 
if the scales are plenty the elevation is more manifest. 

The scales are peculiar and characteristic of the affection. 
They are formed in great abundance, and are cast off in 
profusion; the more active the inflammation the larger the 
quantity produced and discharged, so that, although at all 
times present, their number may vary. They possess a 
whitish, glistening, mother-of-pearl color. They are imbri- 
cated, and form laminae, which adhere but slightly to their 
bed. They may be readily scratched oft', and when the skin 



psoriasis. 293 

is thoroughly denuded, a bright red surface may be seen, 
which inclines to bleed, in the form of minute, pin-point 
drops. But there is never at any time any watery discharge; 
the patch, with the exception of a drop or two of blood 
provoked by scratching, always remaining dry and scaly. 
Fissures not infrequently exist, especially when the disease 
has attacked the joints or parts exposed to motion; they 
are likewise common upon very large patches, involving, 
for example, the thighs or buttocks. 

The degree of inflammation attending the process may 
vary exceedingly. At times symptoms of this kind are 
highly developed, as is manifested by the heat, swelling, 
burning, itching, and redness, while at other times most of 
these signs will be absent. More or less itching usually 
attends the disease, particularly at the commencement or 
when it is extending itself. Burning is also a common 
symptom when considerable surface is attacked with active 
inflammation. In grave cases only is the affection ushered 
in by febrile disturbance ; it is never marked. 

Psoriasis is a conspicuously chronic disease, for, although 
individual patches may disappear, others are apt to show 
themselves in various parts of the body; in this way the 
disease may continue for a long period. Even when all 
traces of it are lost for the time, relapses are the rule, which 
may occur at brief or at long intervals. 

The eruption assumes differences as to the size and shape 
of the patches, some of which are of such frequent occur- 
rence as to be worthy of special names. These terms simply 
denote the form or outline which the disease has taken on, 
and do not apply to any difference in the character of the 
anatomical lesions. When psoriasis occurs as a small, pin- 
head sized eruption it is known as psoriasis punctata. 
This is a rare form of the disease, for, although all cases 
begin in this manner, they seldom remain in this state, 
but, as a rule, quickly pass on to more developed and ex- 
tensive forms. Psoriasis guttata is the name given to 
express the affection when it has assumed the form and size 
of drops. This is more commonly seen than punctata, 
though the process rarely stops at this stage for any length 



294 EXUDATIONS. 

of time. Psoriasis nummularis, where the eruption resem- 
bles variously-sized coins, is the next stage encountered. 
The affection not infrequently ceases to grow when it has 
arrived at this period, and often remains in this condition 
throughout its career. At times the patches clear away in 
the centre, leaving the skin here normal, while they continue 
extending upon their periphery, after the manner of tinea 
circinata; when this occurs the condition is called psoriasis 
circinata. These circles are very apt to coalesce sooner or 
later in the course of their existence, forming more or less 
broken semicircles and segments of circles, which may pre- 
sent a figured, festooned or ribbon-like appearance, to which 
the name psoriasis gyrata has been given. When the 
patches are large, and irregular as to shape, covering a con- 
siderable amount of surface, the term psoriasis diffusa is 
employed to express the condition. 

As regards the size of the individual patches, they differ 
very much according to the severity of the process and 
other circumstances. At times they attain great size, and 
may be from three or four to eight inches in diameter ; where 
two or more patches have joined by their spreading into one 
another, extensive areas may exist, covering a considerable 
portion of a limb or the trunk. 

Psoriasis may occur upon any part of the body, though 
it manifests itself upon certain regions in preference. The 
extensor surfaces of the limbs are particularly prone to the 
eruption.* The elbows and knees are frequently the first 
parts of the body attacked, and slight patches may exist 
here without the disease being present elsewhere. The 
back is more commonly involved than the chest, although 
both regions suffer. The face is more rarely attacked, but 
the scalp is often the seat of the disease. The palms and 
soles may also be invaded, either alone or in connection with 
the affection upon other parts of the body. The nails are 
at times attacked, but seldom, if ever, unless the eruption 
exists also upon the skin. 

Psoriasis offers certain differences in the appearance of 

* See Plate B, Psoriasis, Part I., in the author's Atlas of Skin Diseases. 



psoriasis. 295 

the eruption as it exists upon one part of the body or an- 
other. Upon the scalp it frequently shows itself in the form 
of irregular bands or streaks of eruption ; the patches may 
also be isolated, as upon the trunk. The hair is apt to fall 
out after it has existed for some time, but usually grows 
again after the disease has disappeared. Psoriasis attacking 
the scalp is apt to extend itself somewhat upon the non- 
hairy parts ; thus it is frequently seen about the ears, and 
also upon the forehead just beyond the line of the hair. 
When on the scalp alone it is usually difficult of diagnosis. 
Psoriasis, probably, never occurs upon the mucous mem- 
branes; I have never seen it here.* It is not contagious. 

Etiology. — The cause of this disease varies in different 
cases, there being no one appreciable known cause which 
occasions the eruption. On the contrary, it is seen to arise 
in conditions of the body which are diametrically opposite 
to each other, as in anaemia and plethora. Unquestionably, 
there exists in some individuals a predisposition to the affec- 
tion, which may be either inherited, or developed from some 
inappreciable cause. In these instances the disease shows 
itself at various times during the life of the patient. 

Psoriasis is generally encountered in those who have the 
best of general health, in those who are well nourished and 
stout, and also in those who have otherwise a tine, clear 
skin. On the other hand it is also seen in persons who 
are much broken down in health ; in the spare and poorly 
nourished, as in those who are nursing. Psoriasis occurs in 
both sexes in about equal proportion. It may make its first 
appearance at any time of life after early childhood, but, 
as a rule, it rarely shows itself before puberty. It never 
occurs in infants or very young children. The common 
period for its manifestation is at about the age of twenty, 
but it may also first appear much later in life. Psoriasis 
may be inherited, but according to ni}- experience rarely so, 
for the majority of cases encountered cannot be traced to 

* Cases of so-called psoriasis of the mouth, and especially of the tongue, are 
not psoriasis, but other forms of disease. See papers by W. Fairlie Clarke, 
Practitioner, Aug., 1874, and Brit. Med. Jour , March 14 and 28, 1874; also, 
" Le Psoriasis Buccal," Paris, 1873, by Debove. 



296 • EXUDATIONS. 

either father or mother. It is never produced by syphilis. 
It is a disease in no manner connected with syphilis, either 
directly or remotely. Syphilis gives rise to certain forms of 
eruption which closely resemble psoriasis, but true psoriasis 
— a simple disease of the skin, attacking no other organ of 
the body — is an affection distinct from syphilis. 

It occurs among the rich and the poor. It is found 
among all occupations without noteworthy difference, affect- 
ing those who indulge in exercise as well as those who lead 
sedentary lives. It is one of the commonest diseases of the 
skin, taking rank, numerically, in America, after eczema 
and diseases of the sebaceous glands. My experience at the 
Dispensary for Skin Diseases, Philadelphia, gives me sixty 
cases of psoriasis in every one thousand cases of skin dis- 
ease. The seasons possess some influence upon it, but not 
so much as upon certain other diseases, as, for instance, 
eczema ; it is usually worse during the winter. Food and 
drink have little or no effect in the original production of 
the disease, though when once the process has taken posses- 
sion of the skin it may at times be modified by both food 
and drink. Psoriasis is at times noted to be associated with 
gout and rheumatism, although the relation which it bears 
to these general diseases is by no means, as yet, clearly or 
satisfactorily made out.* The relationship is not, I think, 
of so close a nature as that which exists between these dis- 
eases and eczema. 

Pathology. — The disease consists in a hyperemia of the 
affected portion of the skin, accompanied with the free 
formation of epidermic cells. This condition is present 
from the very commencement, and exists throughout its en- 
tire course. The disease has a pronounced character, from 
which it never varies, rendering the pathological process 
one of the most definite which is encountered upon the 
skin. The degree to which the inflammatory symptoms 
may attain is variable, and dependent upon the cause. 



* For further information upon this subject see a comprehensive and able 
paper " On the Nature of the Gouty Vice," by Dr. Wm. H. Draper, of New 
York. American Clinical Lectures, vol. i., No. xii., 1876. 



psoriasis. 297 

The pathological anatomy has been studied by several 
German investigators. According to Hebra, who has had 
opportunity of examining several cases of psoriasis after 
death, in patients who had died from intercurrent diseases, 
there remains very little to be seen upon the body. With 
the naked eye it is observed that the redness of the patches 
has left the surface, and that the scales are seated very 
superficially upon the skin. Pieces of skin excised and 
examined with the microscope fail to show any decided 
deviation from health. G. Wertheim and Neumann excised 
portions of skin from living cases of psoriasis and examined 
them microscopically. The former observer found the pa- 
pillae greatly enlarged, with marked distention of the blood- 
vessels of the skin. Neumann,* who has of late repeatedly 
excised portions of psoriatic skin, states that he finds the 
epidermis and rete Malpighii highly developed, and the 
papillae considerably enlarged. The corium is filled with 
an abundant cell growth, which is seen especially along the 
vessels. It occurs principally in the upper layers of the 
corium, and in the apices of the papilla?. From his inves- 
tigations he concludes that psoriasis must be viewed as a 
disease of the upper layers of the corium and the papillae, 
accompanied with marked cell-proliferation. 

The scales of psoriasis, examined under the microscope, 
show nothing peculiar or characteristic. They exist in great 
abundance, and are made up of masses of epithelial cells, 
many of which are imperfectly formed. 

Diagnosis. — The diagnosis of typical psoriasis does not pre- 
sent any difficulty, but there are cases frequently encoun- 
tered where the lesions are very imperfectly developed, and 
where the appearance of the disease calls for more than 
casual observation. Psoriasis, according as it occurs upon 
one portion of the body or another, is easy or difficult of 
recognition; thus, when upon the trunk it is usually char- 
acteristic, while upon the scalp it is often irregular in de- 
velopment and obscure. Commonly it exists as a diffused 
or scattered eruption, extensively present over the various 

* Loc. cit., p. 221. 



298 EXUDATIONS. 

regions of the body, and by taking into consideration the 
whole aspect of the disease the difficulty in ^diagnosis will 
be greatly lessened. Where there is doubt, the history of 
the case may be referred to, a point which will be of material 
assistance in forming an opinion. 

Psoriasis may be confounded with eczema squamosum, 
syphiloderma squamosum, tinea circinata, lupus erythema- 
tosus, and seborrhoea. 

Eczema. — Occurring upon a limited portion of the body, it 
not infrequently bears a close resemblance to the squamous 
form of eczema. This is particularly the case when but one 
or two imperfectly-defined patches exist upon the arms or 
legs. The appearance of the two eruptions in these in- 
stances is often strikingly similar, and the diseases may 
readily be confounded. The symptom of itching may or 
may not be present in psoriasis, and therefore neither its 
absence nor its presence can be relied upon as a means of 
diagnosis. In eczema, however, it is always present, and to 
a much greater degree than in psoriasis. In the majority of 
cases of eczema there will be found an account of the dis- 
ease having been at some time in its course moist or wet. 
This is a symptom in the history of eczema which will 
often prove of value as an aid to diagnosis. Psoriasis, it 
is to be remembered, is invariably a dry, scaly disease, 
never at any time in its course showing any sign of moist- 
ure. The scales of psoriasis are always much more abun- 
dant, larger, and whiter than those of eczema. The patches 
of psoriasis are usually well defined as to outline, while those 
of eczema generally exhibit an indistinct border, fading away 
into the healthy skin. 

Syphilis. — Psoriasis and the papulo-squamous syphiloderm 
are frequently mistaken for each other, the diagnosis between 
these two diseases being at times extremely difficult. The 
papulo-squamous syphiloderm at times, indeed, resembles 
psoriasis very closely. There are, however, points of dif- 
ference which always enable one to differentiate them. 
Psoriasis has a decided tendency to occur symmetrically; 
when present upon one side, it is the rule to find it on the- 
corresponding part. This observation does not apply to the 






psoriasis. 299 



syphiloderm, for it seldom disposes itself with any degree of 
symmetry, except in connection with the palms or soles, 
and even here it is subject to variation. Psoriasis inclines 
to involve a large portion of the surface at the same time ; 
the squamous syphiloderm rarely does. Psoriasis throws 
out an exuberant product in the shape of characteristic 
scales; in syphilis these are scanty. Psoriasis attacks re- 
mote parts of the body at the same time, as, for instance, 
the head and the lower limbs; syphilis confines itself, as a 
rule, to one region of the body. In psoriasis the elbows and 
knees are very apt to be affected ; in syphilis these regions 
are seldom involved. Occurring upon the palms or soles 
alone, the disease in the majority of cases will prove to be 
syphilis rather than psoriasis. 

The color of the patches in both affections is reddish, but 
it is likely to be of a much brighter and more inflammatory 
tint in psoriasis, while in syphilis it is dull red or ham-colored. 
The scales iu psoriasis mask the color of the skin and give 
the patch a whitish or mother-of-pearl hue; in syphilis they 
are always thin, and scanty, and do not, as a rule, dis- 
guise the color of the skin. The infiltration- in a patch of 
psoriasis is less marked than in syphilis ; this may be deter- 
mined by taking a fold of the skin up between the fingers. 
A psoriatic patch shows infiltration with marked hypere- 
mia; a syphilitic one, the deposit of a firm, new, cellular 
material. 

The age of the patient may offer some clue to the diagno- 
sis. In the majority of cases psoriasis will have manifested 
itself before the age of twenty; this form of syphilis rarely 
appears before adult life. The courses of the two diseases 
are quite different. Psoriasis is apt to have lasted for years, 
either continuously or in an off-aud-on manner; syphilis 
seldom remains in one form for any length of time. Other 
points of value in the history may be brought out. There 
should be no account of the various symptoms of syphilis 
in psoriasis; it may or may not be possible to elicit them 
from the patient in the syphiloderm. Itching may, but 
seldom does, accompany this form of syphilis ; it is not 
uncommon and is often marked in psoriasis. In obscure 



300 EXUDATIONS. 

cases the effect of treatment will decide as to the nature of 
the lesion. 

Tinea Circinata. — Psoriasis at times resembles tinea cir- 
cinata, but the patches of the latter disease are less inflam- 
matory, red, and infiltrated. The scales in psoriasis are very 
much more abundant than in tinea circinata; they are, 
moreover, always more bulky and whiter in color. Tinea 
circinata shows no disposition to symmetry in the arrange- 
ment of the patches, nor are the knees and elbows affected. 
The history of the two diseases is very different. The mi- 
croscope establishes the presence of a fungus in the scales 
of tinea circinata; no parasite is to be found in those of 
psoriasis. There is never any history of contagion in pso- 
riasis; there usually is in tinea circinata. 

Seborrhoea. — Seborrhoea not infrequently presents appear- 
ances similar to those of psoriasis, both on the scalp and on the 
body, about the back and chest. On the scalp the scales in 
seborrhoea are finer, smaller, and more disseminated than in 
psoriasis; they are, moreover, yellowish in color, greasy, and 
sebaceous in character. Psoriasis of the scalp occurs in dis- 
tinct areas of disease; seborrhoea is apt to involve the whole 
surface. The patches of psoriasis are reddish and infiltrated; 
the scalp in seborrhoea is usually pale, or at times hypersernic, 
but not infiltrated. Psoriasis rarely attacks the scalp with- 
out showing some signs at the same time upon the trunk 
or limbs; seborrhoea commonly has its seat upon the scalp 
alone. 

Lupus Erythematosus. — This disease can be mistaken for 
psoriasis in its earliest stage only. The obvious involvement 
of the sebaceous glands, as shown by their patulous ducts, 
will serve to distinguish it from psoriasis. Lupus erythema- 
tosus almost invariably attacks the face, and is only rarely 
seen upon other parts of the body; psoriasis seldom appears 
upon the face in the form of large patches. Lupus erythe- 
matosus' presents yellowish, sebaceous scales; psoriasis white, 
dry, imbricated scales. Lupus erythematosus is very chronic 
in its course; psoriasis changes its seat and appearance from 
time to time. 

Treatment. — This is to be considered under two heads, 



PSORIASIS. 301 

constitutional and local, both of which methods of treatment 
are of value and require extended notice. It is usual and 
proper to employ the two forms of treatment at the same 
time, for psoriasis is found to be one of the most obstinate 
of the inflammatory diseases, demanding every available 
means for its relief. 

Constitutional Treatment. — Before undertaking to pre- 
scribe for a case of psoriasis there are a number of points 
which should be ascertained. The disease should first be 
viewed in its totality, and a thorough study made of its his- 
tory before any plan of attack is adopted. It will be found 
that different methods of therapeutics are called for with the 
various cases that are met with, and that a course of medi- 
cine which would be of service to one case would be of no 
benefit to another. Attention should be directed to the 
general health of the patient: whether he be strong and 
fleshy or delicate and spare ; also whether there be any func- 
tional derangement which might act as a cause of the attack. 
Regard must be given to the duration and course of the dis- 
ease ; how long it has existed ; whether it has been upon 
the patient continuously, or whether it has tended to come 
and go from time to time or at stated intervals ; whether it 
is slight or extensive; and, finally, whether a recent affec- 
tion or one of long standing. These and similar points are 
all of value in aiding us to institute a rational and satisfac- 
tory treatment. 

Among the medicines of most use in treating psoriasis I 
shall first speak of arsenic; other remedies are also em- 
ployed, but this one is unquestionably of the greatest ser- 
vice. For the majority of cases arsenic, given judiciously, 
is the most efficacious medicine at our command. I add 
judiciously, because it is frequently prescribed in improper 
doses and the patient allowed to continue its use indefinitely, 
causing toxic and Unpleasant effects, without affording relief. 
Arsenic, like every other potent drug, should be admin- 
istered with due regard to the general condition of the 
patient's health, which should never be permitted to become 
deranged. The individual should be warned against its 
possible disagreeable effects, and should also be constantly 



302 EXUDATIONS. 

under the surveillance of the physician. The disagreeable 
symptoms frequently observed to result from arsenic should 
never be allowed to occur, for the} 7 are not only annoy- 
ing to the patient but do not in any way hasten the cure. 
Arsenic is by no means suitable for every case of psoriasis. 
Nor is it to be prescribed in every stage of the disease. If 
given in the acute stage it is apt to do more harm than good. 
It may be said, the less active the pathological process of 
the disease the more likely it is to be of benefit; and, on 
the other hand, the more acute and hyperaemic the less prob- 
ability is there of its being of service. If the affection, 
then, be very active, and attended with highly inflammatory 
symptoms, it is expedient to withhold its administration 
until this stage has relatively passed away, and the process 
has assumed a slower action. The less irritability, heat, 
itching, and infiltration about the patches the greater the 
chance of the arsenic relieving the disease. It is a grand 
error to think that arsenic is demanded in every stage of 
psoriasis. To procure good results, discretion must be exer- 
cised in its exhibition. 

In order to obtain the remedial effect of arsenic it is neces- 
sary to continue its employment for a considerable period of 
time, not infrequently for several months, although improve- 
ment is usually observed in the course of a few weeks. It 
should be continued for some weeks after the symptoms 
have disappeared, the dose being from time to time de- 
creased. The best and most desirable form of administer- 
ing arsenic is the liquor potassii arsenitis, which admits of 
convenient mixing with other medicines, with which it is 
often prescribed. It may be given with wine of iron, or 
with a bitter infusion, as gentian or calumba, or with syrup 
of orange peel or ginger and water. It should never be 
prescribed alone or pure, the patient being directed to take 
so many drops per dose. This mode has numerous disad- 
vantages, chief among which are that an uncertain number 
of drops are apt to be taken, through carelessness on the 
part of the patient, and also that when taken insufficiently 
diluted it is apt to disorder the stomach. It should always 
be properly diluted with water and taken directly after 



PSORIASIS. 303 

meals, in order that it may become thoroughly mixed with 
the food, thereby avoiding immediate contact with the coats 
of the alimentary canal, which it is inclined to irritate, es- 
pecially when given in large doses. It is ordinarily con- 
venient to order a four ounce mixture, a fluidrachm being 
given for each dose, three times a day. 

A formula which I frequently prescribe is the following: 

R Liq. Potassii Arsenitis, f^iss ; 

Vini Ferri q. s. ad f^iv; 
M.— Sig. One teaspoonful, with a wineglassful of 
water, three times daily ; to be taken directly after meals. 

The dose here is three minims; it may be varied to suit 
the case. In an adult it is proper to begin with not more 
than three minims per dose, which quantity may be in- 
creased. The dose most suitable to the majority of persons 
is three minims. Four, five, and even ten minims will often 
be tolerated; but, taking a number of individuals, it will 
be found that the majority will not be able to take more 
than three or four minims for any length of time without 
derangement of the system. Arsenious acid, made into 
pills, is also a mode of administering this remedy, but it is 
not so desirable a form. 

The Asiatic Pills, as they are called, are employed in 
various strengths, and have considerable reputation abroad 
in the treatment of psoriasis ; but they are apt to produce 
gastric trouble, and are not tolerated so well as Fowler's 
solution. Their composition is as follows : 

R Acidi Arseniosi, gr. ii ; 

Piperis Nigri, ^ii ; 

Pulv. Glycyrrhizae Pad., ^ii. 
M. — Ft. in pil. no. xl. div. 
Sig. One pill, three times daily, directly 
after meals. 

The unpleasant symptoms arising from the use of arsenic 
should always be borne in mind, so that should they occur 
they may not be overlooked. These effects vary exceed- 
ingly in different individuals. There are some persons who 
are extremely susceptible to the influence of this mineral, 



304 EXUDATIONS. 

and who are poisoned by it with the smallest dose. I have 
known half minim doses to be sufficient to bring on alarming 
symptoms, such as redness, heat, dryness, and irritability of 
the fauces, pain in the eyeballs, watering of the eyes, injection 
of the conjunctiva, pains in the head, and derangement of 
the alimentary canal. Some if not all of these symptoms are 
usually present when the individual is under the toxic effect 
of arsenic, whether from a small dose, on account of an idio- 
syncrasy, or from a larger quantity saturating the system. 
Under such circumstances the medicine should be discon- 
tinued until the normal condition has been regained, when 
it will be proper to guard against a repetition of such acci- 
dents. The disagreeable effects usually subside at once upon 
the suspension of the remedy. Arsenic is a safe medicine 
when given under the care of a physician. But it should 
not be prescribed incautiously, any more than mercury or 
strychnine. 

Iron is another remedy of some value in certain cases of 
psoriasis. It acts beneficially where there appears to be 
lack of normal strength and tone. In women who have 
been nursing, in young persons of spare frame, and in 
those broken down in general health, the various prepara- 
tions of iron often prove of service. 

To the same class of cases cod-liver oil may be ordered 
with good result, and a combination of this remedy with 
iron may often be employed with advantage. The use of 
the oil should be persevered in for some weeks before it is 
abandoned. But the cases must be selected if improvement 
is to be looked for under this plan. 

Phosphorus has been used with some success, although 
it cannot be regarded as a reliable remedy. It has of late 
again been tried by Hardy, of Paris, Eames, of Dublin, and 
others, with varying results. It is best given in capsules, 
in the dose of about one-twentieth of a grain, three times 
daily. According to my experience, it usually produces 
more or less gastric disturbance. 

Cases are encountered where the free use of alkalies 
proves of service in psoriasis. In patients who have a 
rheumatic or gouty tendency, or where there are allied con- 



PSORIASIS. 305 

ditions, the liquor potassae may be prescribed in ten and 
twenty drop doses, largely diluted, three times daily, after 
eating. In these cases the salts of ammonium, potassium, 
and sodium are also very serviceable. The carbonate of 
ammonium, in from ten to thirty grain doses, well diluted 
with water, is favorably spoken of by Dr. McCall Anderson. 
The acetate of potassium, in half drachm doses, largely di- 
luted, is a remedy from which I have frequently obtained 
excellent results in highly inflammatory cases. The various 
natural alkaline springs may also often be prescribed with 
beneiicial result in these cases. Those of Vichy, France, 
Saratoga (Yichy Spouting Spring), and others containing 
like ingredients, are the most valuable. 

Saline purgatives may occasionally be of value in pro- 
moting a better condition of the general health ; but these 
remedies are to be employed only to correct manifest de- 
rangements which the physician may detect in the case 
before him. 

The diet in psoriasis is to be prescribed according to the 
supposed requirements of the case in hand. As a rule, it 
matters little what psoriatic patients eat or drink, the disease 
not appearing in any way to be influenced by the amount or 
kind of food taken. Exclusive animal diet, taken for a 
period of weeks, is known to have been followed by the dis- 
appearance of the disease, as in the case of Dr. Passavant, of 
Frankfort, Germany. Uufortuuately, however, such a happy 
result is only exceptional. In a case which seemed to me 
suitable for this mode of treatment I instituted a strict meat 
diet for three weeks, with no appreciable result ; afterwards, 
a strict vegetable diet, at the end of which time the patient 
appeared to be about in the same condition as before treat- 
ment. 

Local Treatment. — The use of external remedies must 
vary greatly according to the duration of the disease, its 
extent, location, obstinacy, and the stage in which it exists. 
Regard, too, must be paid to the individual whom we have to 
treat, whether, for example, the patient be a man, a woman, 
or a young person, and whether he or she be in a position to 
carry out the plan that may seem most suitable. It is neces- 

20 



306 EXUDATIONS, 

sary to bear in mind that a course of treatment which could 
be successfully accomplished in the ward of a hospital or in 
a private dwelling, would be impracticable in the rooms of 
the poorer classes. In selecting a method of external treat- 
ment, then, it will be important to ascertain to what extent 
the treatment proposed can be followed out. 

The first point to be gained is the thorough removal of 
the scales which are found upon the patches. This may be 
done in one of several ways: by repeated washings with soft 
soap and water, by means of plain or alkaline baths, by 
detergent washes, or by caustic ointments. For this pur- 
pose the bath is of especial service, accomplishing the object 
much more effectually and agreeably than any other method. 
When possible, it is always to be employed in all cases of 
psoriasis, for in no affection of the skin is the bath more 
beneficial than in this disease. The psoriatic patient of ex- 
perience, knows full well the comfort, satisfaction, and benefit 
to be derived from the bath. 

If the case be an acute one, with very inflammatory 
symptoms, soothing applications, either of water or of bland 
ointments, must be used, for the skin at this period will not 
tolerate the powerful stimulants which are in place in the 
later stage of the disease. Inunction with olive oil at times 
proves serviceable in highly inflammatory cases, the patches 
being well rubbed with the oil several times in the course 
of the twenty-four hours. Duckworth, of London, speaks 
well of the treatment, and I can also add my testimony to 
its efficacy. The vast majority of cases, however, when they 
present themselves to the physician, are chronic, and are 
ready for stimulating applications. The patches having 
been deprived of their scales, one of the tarry preparations 
may be applied. These constitute our most useful class of 
remedies in psoriasis. Occasionally, however, cases present 
themselves where they are not tolerated upon the skin, even 
in the smallest quantity, and where they must be at once 
abandoned. Eemembering this fact, it is proper never to 
apply any preparation of tar over a large surface until it has 
been ascertained that it agrees with the skin. Where there 
is an idiosyncrasy, or where tar is not suited to the case, 



PSORIASIS. 307 

the parts to which it has been applied immediately become 
red, swollen, hot, itchy, or painful, and feel more uncom- 
fortable than before the application. In the majority of 
cases, however, tar, in the form of an ointment or solution, 
is well borne, and is of great service. 

Pix liquida, the common tar, or oleum cadinum, the oil 
of cade, may be used. Both of these preparations are effi- 
cacious, and may be compounded in various ways. An oint- 
ment composed of a drachm of tar or of oil of cade to the 
ounce of simple cerate may be ordered ; it may also be pre- 
scribed of greater strength. Another preparation which 
may be employed consists in a drachm or more of the oil 
of cade to the ounce of alcohol or cologne water, likewise 
to be rubbed into the patches, with a piece of flannel. In 
the application of any of the preparations of tar it is of some 
moment that they should be used in small quantities and 
effectually worked into the skin. They should be firmly 
rubbed into the part, and not smeared upon the surface. 
This is an important point, and the physician should see 
that it is properly carried into execution. The cleansing of 
the patches and the application of the ointment or liquid 
should be regularly attended to once or twice during the 
day. 

A mixture proposed by Hebra, composed of equal parts 
of pix liquida, alcohol, and sapo viridis, constitutes a prepa- 
ration which is used with great benefit in obstinate cases of 
psoriasis. Anderson has given this preparation the name of 
"tinctura saponis viridis cum pice." The "liquor picis alka- 
linus," referred to in considering the treatment of eczema, 
may also be used, in the same manner as in eczema. For 
most cases, however, the oiritment, of one strength or an- 
other, is to be preferred. 

Apart from the local disturbance to which tar occasionally 
gives rise, there are systemic troubles which may, in certain 
cases, be produced by its absorption through the skin. Of 
these, fever, headache, vomiting of dark colored fluid, dis- 
coloration of the feces and urine, are to be mentioned. Upon 
the suspension of the tar, however, these symptoms rapidly 
subside, and are not followed by serious consequences. The 



308 EXUDATIONS. 

greater the surface coated with tar the more likely is this 
absorption to take place; in the treatment of a case of pso- 
riasis of ordinary severity it is rare to note any such effects. 
The long continuance of the use of tar may at times be fol- 
lowed by an inflammation of the sebaceous glands of the 
face, causing a form of acne, called tar acne. 

Creasote may also be used in the form of an ointment, 
varying in strength from a drachm to four drachms to the 
ounce. Squire, of London, speaks well of it in the strength 
of two ounces to one ounce of simple cerate. 

In cases where it is not practicable. to apply the tar, either 
on account of the odor or of its disagreement with the skin, 
other ointments may be prescribed and used in a similar 
manner. Where the patches are small and limited in 
number, I have frequently obtained good result from the 
ointment of the nitrate of mercury, either in its officinal 
strength or weakened, — from one to four drachms to the 
ounce of simple ointment. The biniodide of mercury, in the 
form of an ointment, from five to fifteen grains to the ounce, 
is also a useful remedy; it is much esteemed in France. It 
is advisable, however, to limit the application of these mer- 
curial ointments to small portions of surface, on account of 
the liability of absorption and salivation. The officinal 
white precipitate ointment, or an ointment of the protiodide 
of mercury, fifteen or thirty grains to the ounce, may also 
be mentioned as being serviceable. 

I have recently used with good result in psoriasis of the 
scalp, a half drachm of the white precipitate to the ounce 
of vaseline. 

In cases where the patches are the size of a coin, and 
very obstinate, they may, as recommended by Anderson, be 
treated successfully with a cantharidal blistering fluid. 

The benefits to be derived from the systematic use of 
sapo viridis in the treatment of psoriasis, as recommended 
by He bra, demand a few words. This soap, which possesses 
sharp caustic properties, may be rubbed into the patches 
without water, and allowed to remain. The operation 
should be repeated twice a day for four or six days; then 
only once a day, until the tenth day ; after which the patient 



PSORIASIS, 309 

is directed to apply nothing for five days, when a bath may be 
ordered. The bath should not be taken until the epidermis 
has begun to loosen itself; if water be applied while the 
soap is still being used, or before the exfoliation has oc- 
curred, tension and a very disagreeable sensation of shrink- 
age of the skin, with Assuring, will happen. 

The soap, either alone or with alcohol, in the form of the 
"spiritus saponis alkalinus" of Hebra, composed of two parts 
of soap and one of alcohol, may be employed with excellent 
result in psoriasis of the head. This may be followed by 
the "tinctura saponis yiridis cum pice," or a mixture of oil 
of cade and oil of sweet almond, a drachm to the ounce. Car- 
bolic acid, ten minims to the ounce of alcohol or glycerine 
and water, is also useful. 

Mention has been made of the bath only as a means of 
getting rid of the scales; it is also to be considered as a 
curative remedy. Various mineral baths are at times of 
benefit in relieving the disease, if not effectually at least tem- 
porarily; they should be employed continuously for several 
hours in the course of the day. Those containing sulphur, 
as those of Virginia and New York (Sharon), are to be 
especially recommended. 

In obstinate patches of psoriasis, of limited size, a solu- 
tion of sulphuret of calcium may be employed with good 
result, as in the following formula : 

R Calcis, ^ss ; 

Sulphuris Sublimati, ^i ; 

Aquae, ^x. 

Coque ad ^vi, deinde filtra. 
Sig. — " Vleminckx's Solution." 

It should be rubbed into the part with a piece of flan- 
nel, until slight bleeding takes place. The patient is then to 
be placed in a plain water bath for an hour, and the patch 
afterwards anointed with a bland oil or cerate. This treat- 
ment is effectual, but painful; it should never be used where 
the disease is at all extensive. One or two rubbings are 
usually sufficient. 

In cases where the eruption is localized, good service is to 



310 EXUDATIONS. 

be obtained from cold water packing. The part — as, for 
example, a limb — is to be wrapped with a cloth wrung out 
of cold water, and this enveloped in oilskin or some other 
impermeable dressing. It may be done at night and al- 
lowed to remain on till morning. More extensive methods 
of cold packing may also at times be employed with ad- 
vantage, the whole body being treated in the same manner 
with wet sheets, and surrounded by blankets in the place of 
oilskin. The patient should be thoroughly enveloped and 
tied up with the sheet, and well wrapped up in a blanket by 
means of straps ; sufficient extra covering should be allowed. 
After remaining in this condition for an hour or two, a cold 
plunge bath may be taken, to be followed by a walk or ex- 
ercise of some kind. Abundance of drink (water) should 
be permitted the patient, thereby promoting perspiration. 
The process is to be repeated once or twice in the twenty- 
four hours. 

Prognosis. — As a rule, psoriasis tends to frequent relapses. 
An attack may last a few months, and under appropriate 
treatment be made to disappear completely, when, after an 
interval of an indefinite period, it will usually again show 
itself. In severe cases relapses occur continually, .the patient 
rarely being entirely free of the disease. On the other hand, 
psoriasis of a mild type — of which instances are not infre- 
quent — must receive a much more favorable prognosis, for 
it is generally amenable to treatment, and remains away for 
a longer or shorter time, according to the cause. Employing 
a combined treatment of external and internal remedies, an 
ordinary case should be relieved in from one to two months. 
It occasionally happens that less time is sufficient; many 
cases, on the other hand, require a longer period. Psoriasis 
of years' duration, especially in old people, is more difficult 
of cure, and is often more successfully handled by continuous 
external treatment than by internal means. Each case en- 
countered, however, will be found to possess certain pecu- 
liarities, which must be consulted as regards treatment. 
Psoriasis left to itself runs a variable course, which it is 
impossible to predict, inasmuch as its manifestations are 
more or less capricious. It is one of the most stubborn of 



PITYRIASIS RUBRA. 311 

the inflammatory diseases of the skin, and is often very 
rebellious to both internal and external treatment. 



PITYRIASIS RUBRA. 

Syn. Dermatitis Exfoliativa. 

Pityriasis rubra is an exudative disease, involving usually 
the whole surface, characterized by a deep red coloration 
of the skin, and the rapid, abundant, and continuous exfolia- 
tion of epidermis in the form of large, thin, whitish scales, 
unattended by thickening of the skin or itching. 

Symptoms. — The affection usually begins in the form of 
small, red, scaly patches upon one or upon various regions 
of the body. These increase rapidly in size and coalesce, 
forming larger patches, which may in a short time invade 
the greater portion or the whole of the surface. In other 
cases the whole skin is attacked at the same time. The dis- 
ease makes its appearance rapidly. The surface is seen to 
be uniformly reddened and to be covered with thin, whitish 
scales, which are being continually cast off and reformed. 
The color is a vivid deep red, which fades away under press- 
ure, leaving a yellowish-red tint. The scales are extremely 
abundant, and are composed of thin, dry, papery, whitish, 
exfoliated patches of epidermis. They are large, varying in 
size from a small coin to several inches in diameter. They 
are more appropriately termed flakes ; at times they resemble 
in outline the tiles of a roof, one overlapping the other. 
They are loose, are seen to be free at one or more edges, 
curled up, and may be picked off without causing pain or 
bleeding. When the skin is deprived of the scales it pos- 
sesses a smooth, more or less shining aspect. When the 
disease is marked the desquamation is exceedingly rapid 
and very abundant, large amounts of epidermis being shed 
in the course of the twenty-four hours. During the night, 
handfuls may be formed, loosened, and accumulated in the 
bed. 

The skin is not thickened ; it may readily be pinched up 
between the fingers, and in this respect differs from the skin 
in psoriasis and eczema. It is always dry. Owing to the 



312 EXUDATIONS. 

dryness of the scales it has a harsh feel. The disease is 
superficial in character, the upper layer of the skin only 
being involved. At times there is oedema, especially of 
the limbs ; stiffness of the joints may also be present. Fis- 
sures are seldom present. The nails may or may not be 
affected; occasionally they are transversely furrowed. The 
whole body is almost invariably the seat of the process, no 
region remaining exempt. The palms and soles at times 
escape. 

As a rule, there are no itching or burning sensations ; 
when present they are slight. The patient complains rather 
of the disagreeable condition of the skin than of marked sub- 
jective symptoms. It has been noted that patients are apt 
to feel cold and to suffer from a constant feeling of chilliness. 
Constitutional symptoms may or may not be present; as a 
rule, they are slight or altogether absent. In some cases, 
however, they have been recorded as being severe, consist- 
ing of repeated febrile attacks, marked elevation of tem- 
perature, and signs of geueral disturbance. 

The disease may be either acute or chronic ; it may con- 
tinue weeks and months, or years. Relapses are not un- 
common. The affection may last for years, recurring in 
attacks, as in Dr. McGhie's case, which was under observa- 
tion through a period of seventeen years, during which time 
many relapses took place. 

Etiology. — It is a disease of adult life, occurring usually at 
middle age; it has, however, been encountered in young 
persons. According to Devergie,* of Paris, who was one of 
the first to describe the disease, it is met with more often in 
women than in men. It is a very rare disease. The causes 
are obscure. 

Pathology. — The process is inflammatory in its nature, the 
exudation taking place very rapidly and continuously. It 
must be viewed as being very similar to that of psoriasis, 
although manifestly more superficial in character. The pap- 



* Traite pratique des Maladies de la Peau, p. 442. Paris, 1857. Both Hebra 
and Wilson also described the disease under consideration, in their respective 
works, at about the same period. 



PITYRIASIS RUBRA. 313 

illary layer alone appears to be involved. The changes 
which occur are probably of the same kind as those of pso- 
riasis. The whole process consists simply in the excessive 
formation and exfoliation of epidermis. 

Diagnosis. — The disease is liable to be confounded with 
eczema squamosum, psoriasis, and pemphigus foliaceus. It 
bears a resemblance to all of these affections, but can scarcely 
be confounded with them if the characters be borne in mind. 
It differs from erythematous and squamous eczema in its 
superficial nature and universal distribution ; in the absence 
of all infiltration and thickening of the skin; in the peculiar 
formation and character of the scales, their rapid production 
and abundance; and, finally, in the absence of itching and 
burning. 

Psoriasis rarely invades the whole or even the greater por- 
tion of the surface; pityriasis rubra, as a rule, attacks the 
whole surface uniformly. The scales, moreover, are very 
different in these two diseases, and are alone sufficient to 
establish the diagnosis. In psoriasis there is always more 
or less thickening of the patches; and, where the process 
is active, there is considerable itching and burning. 

Pityriasis rubra may be mistaken for pemphigus foliaceus, 
which it resembles as regards distribution and the character 
of the exfoliation. In pityriasis rubra, however, there is no 
attempt at the formation of bullse; the process is always dry. 

Treatment. — Treatment should be directed upon general 
principles, and must vary somewhat with the case under 
consideration. Locally, inunctions with bland oily substances 
are indicated; the remedies should be soothing rather than 
stimulating. Internally, saline aperients, diuretics, iron, 
quinine, and arsenic may be prescribed, as may seem indi- 
cated.* 



* Interesting cases of this disease have been reported by McGhie, Glasgow 
Med. Jour., vol. v. p. 431, 1858; "Wilks, Guy's Hosp. Keports, p. 310, 1861 ; 
Wilson, Med. Times and Gazette, Jan. 29, 1870; Benson and Smith, Dublin 
Jour, of Med. Sci., vol. xlix. p. 451 ; Tilbury Fox, Lancet, Jan., 1874, p. 294 ; 
G. H. Fox, Archives of Derm., July, 1875, p. 296 ; Percheron, " Etude sur la 
dermatite exfoliatrice generalisee," Paris, 1875 ; Finny, Dublin Jour, of Med. 
Sci., March, 1876. 



314 EXUDATIONS. 



FURUNCITLUS. 

Syn. Furuncle; Boil; Germ., Blutsch war; Fr., Furoncle. 

FURUNCULUS IS A DEEP-SEATED, INFLAMMATORY DISEASE, CHARAC- 
TERIZED BY ONE OR MORE VARIOUSLY SIZED, CIRCUMSCRIBED, ROUND, 
CONICAL, HARD, PAINFUL TUMORS, USUALLY TERMINATING IN CENTRAL 
SUPPURATION. 

Symptoms. — Furunculi may occur singly, or, as is more 
apt to be the case, in numbers. Commonly, they appear in 
successive crops, two, three, or a half-dozen making their 
appearance at the same time, to be followed after they have 
disappeared by another invasion (furunculosis). They are 
always isolated, and are apt to occur at points distant from 
one another. 

The boil first shows itself as a small,. rounded, imperfectly- 
defined, reddish spot, situated in the true skin; even at this 
stage it is seen to be highly inflammatory, hard, and tender 
to the touch. It increases in size gradually, and becomes 
conically raised, its central point exhibiting more or less 
inclination to suppurate. In about a week from the com- 
mencement it arrives at its full development. In size it is 
extremely variable ; it may be as small as a split pea, or as 
large as a silver half dollar. When mature it consists of a 
slightly raised, rounded and pointed, inflammatory forma- 
tion, its centre being marked usually by circumscribed sup- 
puration, termed the core. At times no core forms; it is 
then called a blind boil. Its color is deep red, which is more 
intense towards the centre, gradually fading away on the 
periphery, in the form of an areola. The pain attending 
boils is of a dull, throbbing nature; it is usually more 
marked at night. It is felt as soon as the formation com- 
mences, and increases in intensity until suppuration and 
discharge take place, after which it at once subsides. Re- 
markable tenderness is also a characteristic of the boil, the 
slightest contact causing great suffering. 

The furuncle may attack any portion of the body; no 
region is exempt. It has preference, however, for the 
face, ears, neck, back, axillae, buttocks, perineum, and legs. 
Slight constitutional disturbance is very apt to be present; 



FUKUNCULUS. 315 

it may be quite severe, its extent depending" upon the nature 
and amount of the inflammation. The adjoining tissues may 
be sympathetically affected, manifesting soreness and pain; 
neighboring glands may also be enlarged. 

Furunculi are sometimes noted to occur as a complication 
with other cutaneous diseases, as, for example, eczema. 

Etiology. — The causes which give rise to the production of 
boils are various. Very frequently they are the result of a 
low and depraved state of the system, induced by general 
debility, excessive fatigue, nervous depression, improper 
food and exercise, irregularity of the functions of the body, 
and the like. Not rarely they are encountered in the course 
of other diseases, as in chlorosis, fevers, and similar condi- 
tions, when they are apt to appear in great numbers. Their 
appearance is to be viewed as probably being dependent 
upon a disordered state of the blood, of the nature of which 
we are ignorant. They may occur at any time of life, but 
are more common in youth and old age. In some cases the 
causes appear to be local, depending upon contusions or 
other injuries; they, however, can result from such causes 
only in those cases where there is a predisposition to their 
development. 

Pathology. — The furuncle has its seat in the corium and 
deeper tissues. It may begin in a gland or in the structure 
of the skin itself. It is an inflammation of a peculiar type, 
running a more or less definite course. The disease com- 
mences as a small roundish spot, which increases in size 
until certain dimensions are obtained, when it undergoes 
suppurative change, resulting in the formation of a central 
point or core, which, together with pus, is cast off. The 
furuncle shows no disposition to become diffuse; it is always 
a circumscribed inflammation. After the discharge of the 
core, a cavity of more or less depth remains, showing the 
tissues around it to be hard and infiltrated; after a few days 
it is observed to fill up by granulation, leaving a cicatrix, 
which is apt to be permanent. The central point or core, 
when thrown off, is seen to be composed of a whitish, tough, 
pultaceous mass of dead tissue; its size varies with the 
extent and depth of the inflammation. 



316 EXUDATIONS. 

Diagnosis. — The symptoms of furuncle are so well known, 
that error in diagnosis can scarcely occur. The affection 
differs from anthrax, in that it possesses only one point of 
suppuration, the core, whereas in the latter disease this 
feature is always multiple. The furuncle is, moreover, always 
rounded in form, and conical in shape; the carbuncle may be 
rounded or oval in outline, but is always flat. Furuncle is 
small, being seldom larger than a walnut; carbuncle varies 
in size from a large coin to five or ten inches in diameter. 
Furuncle is exquisitely sensitive and painful to the touch; 
carbuncle is not particularly sensitive to the touch, the pain 
being of a spontaneous nature. Furuncle generally occurs 
in numbers, either at the same time or in the form of suc- 
cessive crops; carbuncle is almost invariably single. 

Treatment. — Constitutional and local treatment are both 
called for, the object being to prevent the formation of new 
boils and at the same time to care for those which exist. 
Each case demands special study, with the view of ascer- 
taining the cause of the trouble ; as already stated, this will 
be found to vary in different cases. The functions, if dis- 
ordered, are to be regulated by appropriate means. Tonics 
may in almost all instances be directed with good result. 
Arsenic, iron, quinine, and the mineral acids are all useful 
remedies. Arsenic, in from two to four minim doses three 
times daily, will be found serviceable in many cases ; it is, I 
think, our most valuable remedy. Drs. Bulkley and Weisse, 
of New York, inform me that they have obtained favorable 
results from the employment of the sulphites and hyposul- 
phites of sodium, given in fifteen or thirty grain doses, every 
two or three hours through the day. The diet should be 
generous, embracing the most nutritious articles of food. 
Hygienic measures play a very important part in the treat- 
ment. The patient should sleep in a well-ventilated room. 
Exercise should be freely indulged in. Change of air is very 
desirable; not infrequently it is followed at once by manifest 
benefit. 

Locally, hot poultices of flaxseed meal, applied continu- 
ously until the core has been cast off, afford the most relief. 
Cold water dressings may also be employed in the first stage. 



FUBUsrcuLus. 317 

Prognosis. — ^Vhere they tend to appear in crops they are 
apt to be rebellious to treatment. Where great numbers of 
them are present, the general health of the patient is usually 
much impaired; in such cases the treatment should be ener- 
getic, a change of air, travelling, often proving of especial 
value in arresting their further development. 

With the name of hydroadexitis Verneuil* and Bazinf 
have described at length an affection, which is to be viewed as 
a variety of furuncle, having its starting-point in a sweat gland. 
It consists in the formation of one or more small, inflamma- 
tory tumors, seated about the sweat glands, ordinarily ter- 
minating in suppuration. In the first stage it is character- 
ized by a circumscribed, indolent induration, which in a 
short time increases in size, and is accompanied with in- 
flammatory symptoms : when at its height it is the size of a 
pea or a cherry, is bright red or violaceous in color, and con- 
tains pus. Rupture of the tumor, followed by discharge of 
the contents, takes place, when the disease suddenly termi- 
nates ; in some cases the discharge continues, constituting a 
more or less chronic suppurating tumor. Usually, however, 
it is an acute disorder. A succession of these formations 
may, from time to time, show themselves. The disease 
may attack one or several glands; if several close to one 
another are the seat of disease, a considerable area of in- 
flammation may result, forming an uneven, dark red, painful 
tumor. The usual seat of these tumors is in the axilla, 
around the nipple, and about the anus and perineum ; they 
are also encountered upon the face, and elsewhere over the 
body. The affection differs from furuncle in having a deep 
origin, and in the absence of pointing and a core; it is a 
form of abscess. The treatment is that of furuncle. 

Under the names of Aleppo Bouton, Boil, or Evil, Delhi 
Boil, and Biskra Bouton, certain diseases resembling one 
another have from time to time been described by writers. 

* Archives Generales de Medecine, 1854. 

r Affections Generiques de la Peau, vol. ii. p. 319. Paris, 1865. 



318 EXUDATIONS. 

The first of these is found at Aleppo, Bagdad, and the sur- 
rounding country; the second in India; and the third in 
Algeria and elsewhere along the coast of Africa. They are 
endemic in these countries. Much confusion has long ex- 
isted as to their true nature. They have been described as 
being allied to furuncle, although possessing a much more 
chronic course. They are characterized at first by the for- 
mation of a papule or tubercle, which soon becomes a pus- 
tule, finally terminating in ulceration, followed by a cicatrix. 
According to recent investigations and studies, it is highly 
probable that these three diseases are identical, but modified 
by nationality, climate, and other causes. 

For an account of the diseases, in detail, I would refer the 
reader to the recent interesting and valuable writings of Til- 
bury Fox,* and Edward Geber,f of Vienna, upon the subject. 
The latter of these gentlemen remained some time in Aleppo 
for the purpose of studying the disease, and arrived at the 
conclusion that all of the cases of so-called Aleppo Bouton 
were modified forms of syphilis, lupus, or scrofula. 

ANTHRAX. 

Syn. Carbunculus ; Carbuncle ; Germ., Brandschwar. 

Anthrax is a deep-seated disease, characterized by a hard, 
more or less circumscribed, dark red, painful inflammation 
of the skin and subcutaneous structures, variable as to size, 
terminating in a slough. 

Symptoms. — The disease is usually ushered in with a chill, 
fever, and symptoms of general disturbance. The skin is 
felt to be hot and painful, and there is seen to form a hard, 
brawny, more or less circumscribed, flat, diffuse swelling, 
reddish or bluish in color, extending deep into the subcu- 
taneous tissues. It is very painful, and is accompanied with a 
burning sensation, especially during the first week. Within 
a fortnight it will usually have arrived at its height, and then 

* Loc. cit., p. 241. Also " On Certain Endemic Skin and other Diseases 
of India and Hot Climates Generally," by Tilbury Fox, M.D., and T. Far- 
quhar, M.D. London, 1876. 

f Vierteljahresschrift fur Derm, und Syph., Viertes Heft, 1874. 



ANTHRAX. 319 

consists of a remarkably deep-seated inflammation, charac- 
terized by induration, and a dark or livid red color of the 
skin. The tissues now begin to soften, and the skin becomes 
gangrenous, breaking down at numerous points, forming 
perforations, through which centres of suppuration may be 
noticed, either as whitish fibrous plugs, cores, or as cavities, 
from which a yellowish, sanious fluid oozes forth. The sur- 
face now has a cribriform appearance; it is perforated like a 
sieve. The whole mass of tissue results in a slough, which 
comes away as soon as detached ; this process takes place 
either at once or by degrees, pieces being cast off from 
day to day. The slough having been discharged, a large, 
open, deep ulcer, with everted edges and uneven base, is 
seen to exist, which granulates and tills up slowly, leaving, 
finally, a more or less pigmented, permanent cicatrix. 

The course which carbuncles pursue varies according to 
the age of the patient, vitality of the part, recuperative 
power, and other circumstances. Their duration will depend 
upon their size; when severe they last from six to eight 
weeks. Anthrax is usually single. Its favorite seats are 
upon the back of the neck, shoulders, back, and buttocks; 
the head and face are also attacked. It is a very serious 
disease, and when extensive, especially in the elderly, may 
terminate fatally. Boils are very apt to appear about the 
borders of carbuncle, either singly or in groups. 

Etiology. — The causes of anthrax are obscure. They are 
probably of a nature similar to those which give rise to 
furuncle. The disease, however, is commonly noted to occur 
in those who are broken down in general health, whatever 
be the cause of this condition. It is noted to attack the 
abstemious as well as the intemperate. It is usually en- 
countered in middle and old age, and is more often observed 
in men than in women. 

Pathology. — The pathological anatomy of carbuncle is sim- 
ilar to that of furuncle. The disease has been aptly likened 
to a group of furuncles; but, as a process, it is much more 
destructive than the boil. Death of tissue is limited to one 
point in furuncle; in anthrax it is diffuse, numerous points 
being simultaneously attacked, the whole surface invaded 



320 EXUDATIONS. 

terminating in gangrene and a huge slough. The process 
is a deeper one than in furuncle, very frequently extending 
down to the fasciae and muscles. The tissue of a carhuucle 
before the slough has formed is quite hard and firm to the 
touch. After the slough has been cast off, the edges of the 
ulcer are likewise noted to be indurated and everted. 

Diagnosis. — The disease will be readily distinguished from 
furuncle by its size, flatness, course, multiple points of sup- 
puration, and the character of the slough. It may be 
mistaken in its early stage for erysipelas; later, however, 
this error would be dissipated by the presence of the pain, 
slough, and other symptoms. 

Treatment. — The treatment should be both constitutional 
and local ; the former will depend upon the nature of the 
case under consideration. One case, for example, calls for 
stimulation ; another will do well without it. The treatment 
should be conducted upon general principles. Supporting 
measures are, however, demanded in the majority of cases, 
when the most nourishing diet, together with milk-punch, 
is to be freely administered. Tincture of the chloride of 
iron and quinine are the two remedies from which most 
benefit is to be looked for. Anodynes, especially opium, are 
useful, and are to be prescribed in full doses in the early 
stage, for the purpose of insuring rest at night. Hygiene 
is quite as important as medicine. The patient should be 
allowed abundance of fresh air, and also exercise, when the 
region attacked will permit of it. All measures calculated 
to improve the general condition should be instituted and 
insisted upon. 

Local treatment is also of importance. Early in the course 
of the disease, towards the third day, crucial incisions, as 
recommended by many surgeons, may in some cases be 
made with advantage; when the carbuncle is very hard and 
painful this procedure will at times afford great relief. Ou 
the other hand, the majority of cases do equally well without 
cutting.* 



* In corroboration of this view, see an admirable clinical lecture on the 
treatment of carbuncle, by Sir James Paget. " Clinical Lectures and Essays," 
London, 1875. 



ANTHRAX. 321 

Strict attention to cleanliness is most important. Various 
dressings have been recommended. Hebra speaks in favor 
of cold applications (cloths wrung out in ice-water or ice- 
bags) in the early stage, stating that, as a rule, more relief is 
to be obtained from this source than from poultices. Warm 
fomentations are, however, to be employed as soon as sup- 
puration has begun ; they tend to relieve the tension of the 
tissues, and hasten the discharge of the slough. The poul- 
tices may be made of flaxseed or linseed meal ; they should be 
changed frequently. The parts should be kept scrupulously 
clean, the discharge being removed as soon as it makes its 
appearance on the surface. The slough should be carefully 
picked out with the forceps as soon as detached, and the 
ulcer washed with carbolic acid and water, a few minims to 
the ounce. The ulcer which remains is to be treated in the 
manner of a simple ulcer. 

Prognosis. — This should be guardedly expressed. In the 
early stage of the disease it is impossible to state to what 
extent the carbuncle will spread; it may be two or three 
or six or ten inches in diameter. A fatal termination is 
liable to take place, especially in elderly people who are 
broken down in health; at the same time the mortality, 
taking cases as they are consecutively met with, is not so 
great as is commonly supposed. 

In connection with the subject of phlegmonous inflamma- 
tions are to be mentioned several diseases affecting the skin 
and deeper tissues, which are produced through infection 
with animal poisons.* 

Poisoned Wounds. — Wounds of this character are pro- 
duced by numerous insects as well as by animals. The 
symptoms may be local or constitutional, but are commonly 
the former. A large number of small insects, as certain kinds 
of midges and flies, the mosquito,f flea, and bed-bug, cause 
lesions upon the skin, which vary in kind and degree accord- 

* For a complete description of these diseases the reader is referred to Prof. 
Gross's System of Surgery, Philadelphia, 1872. 

•j- See a paper describing the appearances caused by mosquito poisoning, by 
Dr. White, Boston Med. and Surg. Jour., vol. lxxxv., No. 19. 

21 



322 EXUDATIONS. 

ing to the susceptibility of the individual. The bites of 
these insects at times give rise to appearances resembling 
urticaria and purpura. Bees and wasps not infrequently 
occasion considerable cutaneous disturbance by their stings. 
The bites of many insects and spiders, as, for example, the 
scorpion, and reptiles, met with in hot climates, are extremely 
poisonous, and cause various lesions of a more or less in- 
flammatory character. 

Dissection Wounds. — The symptoms resulting from inoc- 
ulation through contact with dead bodies are various ; they 
may be local, confined to the point of inoculation, or they 
may be general, producing severe constitutional disturbance. 
Usually the trouble is at the seat of a former abrasion of the 
skin, as, for example, upon the hand, which commences by 
the formation of a small vesicle or pustule upon a hard, 
inflammatory base. There is at first more or less burning 
or itching, which is followed by pain, usually extending up 
the arm to the axilla, lymphangitis, and constitutional symp- 
toms. The pustule soon breaks and shows an ulcer, variable 
as to size and character. In other cases the disease is strictly 
local, the lesion being more or less indurated, circumscribed, 
and painful. The epidermis becomes thick and fissured; 
the sore secretes more or less fluid, resulting in a crust; 
papillary growth takes place, and the wound assumes a 
warty, hard, indolent character, which may last for months. 

Pustula Maligna. — Malignant pustule, called by the 
French "eharbon," presents features similar to those seen 
in dissection wounds of a malignant type. The disease is 
due to the inoculation of a peculiar, virulent poison gener- 
ated in cattle suffering from a disorder known by the name 
of murrain or charbou. After inoculation, which usually 
occurs about the hands of those who have to deal with cattle 
and hides, the period of incubation is very brief, often only 
a few hours, when the part is attacked with pain, burning, 
aud itching, followed by the formation of a vesicle or pus- 
tule, with an extensive, hard areola ; the pustule increases 
to the size of a coin, and soon breaks into an unhealthy dis- 
charging ulcer. The constitutional symptoms are usually 
very severe ; the patient not infrequently succumbs. 



EQUINIA. 323 

Equinia, called also Glanders and Farcy, maybe defined 
as a malignant, contagious disease, derived from the horse, 
manifesting itself by grave constitutional symptoms, inflam- 
mation of the nasal and respiratory passages, and a deep- 
seated, pustular, hemorrhagic, ulcerative form of eruption.* 
After inoculation has occurred, there is a period of incu- 
bation, varying from a few days to a week, when marked 
symptoms of general disturbance, prostration, and rheumatic 
pains manifest themselves, followed by a peculiar eruption 
composed of pustules, similar in form to those of vaccinia, 
containing a thick, yellowish product mingled with blood. 
At times the eruption is of a tubercular or vegetating nature 
("farcy buds"); these rapidly disintegrate and result in 
extensive ulcers, accompanied by hemorrhage and gaugrene. 
The lymphatics become inflamed, erysipelatous patches and 
bullae form here and there, which break down into suppu- 
rating and bleeding ulcers. Hard and painful tumors, of 
various sizes, also appear, which rapidly soften into deep 
abscesses. The skin over the whole body is seen to be 
ceclematous, swollen, and ecchymotic. 

The nasal passages and the respiratory tract are affected in 
a most virulent manner. A thick, yellowish, bloody secre- 
tion flows from the nostrils; the mouth aud throat become 
inflamed in patches; the glands enlarge; ulceration and 
gangrene of the mucous surfaces take place as upon the 
skin, and the patient succumbs. It is said that the two 
sets of symptoms, those of the mucous membrane and those 
of the skin, may or may not occur in the same subject. 

The disease always originates in the horse. It is highly 
contagious, and may be contracted either by means of direct 
contact or through the medium of the air. The disease is 
rare. No specific treatment has been recommended. 

DERMATITIS. 

Under this term, signifying simply inflammation of the 
skin, without reference to its cause or clinical features, I 

* The author is indebted chiefly to the writings of Elliotson (Medico-Chir. 
Trans., London, vol. xvi., 1830) and Bollinger (Ziemssen's Cyclopaedia of 
Practical Medicine, vol. iii.) for his knowledge of the disease. 



324 EXUDATIONS. 

have grouped a number of inflammatory conditions similar 
as to their pathology, produced by external agencies, as, for 
example, heat, cold, cutaneous irritants, caustics, etc. Affec- 
tions of this character are of every-day occurrence, and, as 
they happen to be superficial or deep-seated, fall into the 
domain of surgery proper or of dermatology. 

The lesions met with in dermatitis vary according to the 
nature of the cause, the intensity of its action, the suscepti- 
bility of the skin of the individual, and other circumstances. 
In the first stage there exists erythema, of various grades, 
merely, which may remain as erythema or may pass into 
other pathological conditions, as vesicles, pustules, blebs, 
or gangrene. 

The usual clinical signs of inflammation — redness, heat, 
swelling, pain, or itching — are all present in a more or less 
marked degree. The affection may be either diffused, as, 
for example, in dermatitis from poisons, or circumscribed, as 
in traumatic dermatitis. 

The forms of dermatitis most frequently encountered may 
be referred to under the heads of the causes which produce 
them. 

Dermatitis Traumatica. — Here are found all those active 
or passive inflammatory states which exist as the result of 
direct violence to the skin; they include contusions and 
other injuries of a similar character. The irritation to the 
surface arising from ill-fitting garments, shoes, and other 
articles of wear, may also occasion hyperemia and exuda- 
tion. The various conditions referred to in considering the 
simple erythemata may, under adverse circumstances, ter- 
minate in inflammation, varying as to degree. As stated 
in speaking of erythema simplex, the dividing line between 
hyperemia and exudation cannot be drawn sharply ; the 
former frequently borders on the latter without the process 
becoming inflammation in so decided a degree as to be 
worthy of this name. 

Excoriations constitute to the dermatologist one of the 
most important varieties of traumatic dermatitis. They are 
superficial losses of substance of the epidermis and corium, 
accompanied by more or less inflammation, the result of 



DERMATITIS. 325 

scratching on the part of the patient. These lesions have 
been already considered (see p. 48). Excoriations of a 
marked inflammatory character are observed in connection 
with scabies, and phtheiriasis of the body, where the skin is 
lacerated extensively and the lesions are followed by consid- 
erable exudation, thickening, and pigmentation. 

Dermatitis Venenata. — Under this head are included 
numerous inflammatory conditions of the skin, resulting 
from contact with substances which act deleteriously upon 
this organ. The inflammation is of all grades. According 
to the virulence or concentration of the poison and the sus- 
ceptibility of the skin, will the lesions be of an erythematous, 
vesicular, pustular, or bullous character. In the vegetable 
kingdom certain plants are known to possess properties of a 
poisonous or irritant nature when brought in contact with 
the skin ; among these rhus venenata, rhus toxicodendron 
(commonly known as, respectively, poisonous sumach or dog- 
wood, and poison ivy or oak), mezereum, and arnica may be 
mentioned as being productive of most mischief. The rhus 
family exert a particularly deleterious influence upon the 
skin.* Contact, or, in some cases, proximity to the plants 
even, is suflicient to cause the affection. The poison is an 
exceedingly volatile acid, — toxicodendric acid, — which was 
discovered in the toxicodendron by Prof. Maisch, of this city. 

All persons, however, are not equally susceptible to the 
influence of the acid. Some are not affected at all, being 
able to handle the plants with impunity; others suffer but 
slightly, and after contact only ; while not a few are attacked 
by a violent inflammation of the skin, varying in degree from 
an erythematous condition to vesiculation, accompanied with 
swelling, heat, and serious disturbance. Individuals are met 
with who are so susceptible as to be affected by being in the 
neighborhood merely of the plants. The poison is readily 
conveyed by means of the hands, the parts usually first 
attacked, to other portions of the body, and it is in this 



* The subject "has received careful study at the hands of Dr. White, of 
Boston. See a valuable article in the New York Medical Journal, March, 
1873. 



326 EXUDATIONS. 

manner that the eruption spreads. The face and genitalia, 
parts liable to be more or less handled, are very frequently 
seen to be the seat of the disease. The poison, as a rule, acts 
quickly, a few hours not rarely being sufficient to cause symp- 
toms of cutaneous derangement; in other cases several days 
may elapse before marked symptoms develop themselves. 

The eruption may be either of an erythematous or of a 
vesicular character, usually the latter. In typical examples 
the vesicles form rapidly; are remarkable for their irregular 
distribution; vary in size from pin-points to pin-heads; and 
are seated upon a highly inflamed, (edematous surface. 
The vesicles may pass into pustules, or they may become 
blebs, through coalition. When the eruption is at its height, 
swelling, oedema, heat, and itching are all prominent symp- 
toms. The hands, arms, face, and genitalia in the male are 
all usually involved, and are attended by much disfigure- 
ment. At times the greater part of the surface becomes 
the seat of disease, showing itself in the form of scattered 
patches; as a rule, the lesions in these cases consist of a 
mixture of erythema and vesicles. The disease has an acute 
course, the vesicles rupturing spontaneously or from vio- 
lence, the fluid drying into yellowish crusts. The process 
may continue from one to six weeks, according to the severity 
of the attack, and other circumstances, as, for example, treat- 
ment. Under proper local treatment the majority of cases 
recover in the course of a fortnight. 

The anatomical changes which take place are in all prob- 
ability identical with those which have been noted in con- 
nection with eruptions produced by croton oil (see p. 172). 
The process is an acute, simple inflammation of the skin, 
inclining always to spontaneous recovery. Attacking, how- 
ever, individuals who are predisposed to eczema, as must 
not infrequently happen, considering the extent to which 
eczema exists in every community, the course of the eruption 
may become complicated and take on the characters of a 
more or less chronic eczema. It is under these circumstances 
only, it seems to me, that true eczema may be said to follow 
the eruption. 

The treatment should consist of soothing, mildly astrin- 



DERMATITIS. 327 

gent lotions, followed in the later stages by the use of a 
bland ointment or a starch dusting powder. Dilute lead 
water is a popular and useful remedy. Black wash, em- 
ployed as a lotion for a half hour at a time, every three or four 
hours, as recommended by Dr. White, is a very serviceable 
application. Vegetable astringents, as, for example, decoc- 
tion of white-oak bark, are also useful. Towards the close 
of the process, a wash of corrosive sublimate, one grain to 
the ounce of water, may be employed, as in the case of 
eczema or scabies of the hands. 

Of a similar nature is the inflammation of the skin pro- 
duced by the poisonous aniline and coralline dyes, with 
which undergarments are at times colored. Undershirts, 
drawers, and socks dyed with these substances not infre- 
quently cause hyperemia and inflammation of the skin, 
especially when worn in warm weather and before having 
been washed. I have met with several cases in women, 
occurring about the feet and legs, where the dye-stuff was 
found to be in the lining of the shoes, the poison haviug 
penetrated through the stockings. 

Arnica also acts injuriously upon the skin. The tincture 
of arnica, a popular though dangerous remedy for bruises, 
wounds, and various other affections of the skin, not infre- 
quently causes symptoms resembling those produced by the 
rhus plants. 

Mustard and mezereon are also capable of producing 
mischief upon the skin ; when applied carelessly the result 
may be similar to that of the irritants just referred to. 
Croton oil, rubbed into the skin, produces a minute vesicular 
and pustular eruption, accompanied by oedema, swelling, 
pain, and itching; its severity will vary with the amount of 
oil and friction used. 

Mercurial ointment, employed injudiciously in the form of 
inunctions, also occasions at times an eruption similar to 
that of croton oil; this happens seldom, however, and only 
in cases where the skin is extremely susceptible or where 
the substance is applied indiscreetly. 

The deleterious effects following the application of strong 



328 EXUDATIONS. 

acids, as nitric acid, or alkalies and other caustics, are so 
well known as not to require more than mention. Not 
merely inflammation, vesicles, and bullae, but even gangrene 
of the skin, may take place from the use of these prepara- 
tions. 

The various irritants which have been enumerated are 
employed occasionally, especially by hysterical girls, for the 
purpose of simulating disease, as, for example, nitric acid for 
pemphigus, mustard plasters for erythema, etc.* 

Dermatitis Calorica. — Both heat and cold call forth in- 
flammatory symptoms, in the form of burns and frost-bites. 
Burns, whether resulting from artificial heat or from the 
rays of the sun, give rise to the same group of symptoms 
as those produced by the causes already referred to. Ac- 
cording to the extent of the burn will the skin present an 
erythematous, vesicular, bullous, or gangrenous condition. 

Similar lesions, although usually of a much less marked 
character, are observed in connection with frost-bite. 

* In this connection, see an interesting paper by the late Mr. Startin, 
of London, on Feigned Diseases of the Skin. British Medical Journal, 
January 8, 1870. 



CLASS IV. 
HEMORRHAGES. 

Hemorrhages into the skin assume certain external ap- 
pearances, which are designated, according to their form and 
size, as petechias, vibices, ecchymoses, and ecchymomata. 
These may be defined as follows : 

Petechias are roundish or oval in form, and vary in size 
from a pin-point to a finger-nail. 

Vibices are long, narrow, streak-like lesions, varying in 
size from a few lines to an inch or more. 

Ecchymoses are large, indefinitely sized, roundish or ir- 
regularly-shaped patches. 

Ecchymomata consist of extensive extravasations, which 
appear in the form of tumors. 

Cutaneous hemorrhages may occur either as the result of 
external injury, in which case they are termed idiopathic, 
or as a symptom of some internal disease, when they are 
designated symptomatic. 

Idiopathic Hemorrhage. — To this category belong all 
those conditions which are produced by wounds, contusions, 
and other forms of direct violence to the integument, and 
by mechanical vascular disturbances, as in varicosities. In 
these cases the vessels are ruptured and the blood extrava- 
sated in greater or less quantity into not only the skin but 
also the deeper structures. Under this head are to be placed 
the minute, circumscribed hemorrhages produced by the 
bites of various insects, among which the pediculus, flea, 
and bed-bug may be mentioned as giving rise to the most 
mischief. 

329 



330 HEMORRHAGES. 

Symptomatic Hemorrhage. — The hemorrhage here takes 
place spontaneously, showing itself as apparently the only 
disease, as, for example, in purpura simplex; or, as a symp- 
tom in the course of certain severe constitutional diseases, 
as in variola and typhus fever; or, finally, as a secondary 
symptom in other diseases of the skin, as in pemphigus, 
ecthyma, and erythema nodosum. 

The general characters of cutaneous hemorrhage have 
been already stated in the chapter upon the pathology of 
the skin. 

PURPURA. 

Syn. Hemorrhoea Petechialis ; Germ., Purpura; Blutfleckenkrankheit ; 
Fr., Purpura. 

Purpura consists in the spontaneous development of va- 
riously SIZED AND SHAPED, NON-ELEVATED OR SLIGHTLY RAISED, 
SMOOTH, REDDISH, HEMORRHAGIC PATCHES, CHARACTERIZED BY NOT 
DISAPPEARING UNDER PRESSURE. 

Symptoms. — Three varieties are met with. These differ in 
the premonitory symptoms which precede the cutaneous 
manifestation, in the amount of constitutional disturbance 
attending the disease, in the extent of the hemorrhage, and 
in the etiology. The external forms of the lesions, their 
size, shape, number, and color, are likewise found to be 
different. 

Purpura Simplex. — This variety of the disease rarely 
exhibits symptoms of systemic disturbance. Frequently the 
spots are the only manifestations of disease ; at times they 
give rise to so little inconvenience that their presence may 
escape detection on the part of the patient. Occasionally, 
however, patients complain of feeling unwell, of loss of ap- 
petite, and of fatigue on exertion, for some days before the 
cutaneous lesions appear. They often make their appear- 
ance suddenly, in the course of a night, in the form of bright- 
reddish, claret-colored, or purplish, circumscribed, round or 
irregularly-shaped, hemorrhagic spots. They vary in size 
from a pin-point to a pea or bean. They usually occur in 
numbers, their common seat being upon the lower extremi- 
ties ; other regions, however, are also involved. They ex- 
hibit a tendency to appear in a scattered manner, invading 



PURPURA. 331 

a considerable amount of surface, without regularity of dis- 
tribution. They are, as a rule, unaccompanied by subjective 
symptoms. At times, where there is a disposition in the 
skin to the ready development of wheals, these lesions may 
show themselves in connection with the hemorrhage, con- 
stituting purpura urticans, in which case more or less itching 
will be present. The disease is more frequently observed in 
the old than in the young. Its duration may vary from a 
fortnight to several months. The cutaneous lesions are apt 
to relapse, in the form of crops, throughout the course of 
the disease. The causes are obscure; it is noted to occur 
in those who are apparently well nourished as well as in 
those who are in a debilitated state. 

Purpura Rheumatica — Peliosis Rheumatica. — It is ush- 
ered in with more or less fever, lassitude, loss of appetite, 
marked depression of spirits, together with severe rheumatic 
pains throughout the body, more particularly about the joints 
of the lower extremities. In the course of a few days or a 
week, the eruption suddenly makes its appearance over a part 
or the whole of the body, the lesions being most distinct over 
the arms, thighs, and legs. They consist of more or less well- 
defined hemorrhagic spots, pinkish, reddish, or purplish in 
color, varying in size from a split pea to a finger-nail. They 
are either slightly raised or on a level with the surrounding 
skin, and are unattended by subjective symptoms; a general 
soreness, however, is apt to be felt over the whole integu- 
ment. The color of the eruption undergoes marked changes 
from time to time, passing into a variety of yellowish and 
greenish hues, until finally, with the reabsorption of the 
blood, it gradually fades away. 

The disease may last for a few weeks or for months, in 
which case new hemorrhagic spots appear, in the form of 
relapses. The constitutional symptoms, consisting of de- 
pression, loss of appetite and strength, weariness, and allied 
feelings, are apt to remain throughout the attack; they are 
always striking, and are usually alarming to the patient. 
The severe rheumatic pains which precede the hemorrhage 
are apt to abate very materially upon the appearance of the 
eruption. The disease is encountered in both men and 



332 HEMORRHAGES. 

women, more often in the latter, and ordinarily occurs 
during middle life. In certain cases it is associated with 
erythema multiforme. No cause can be assigned for the 
disease. 

The diagnosis is at times difficult, especially in those cases 
in which the lesions happen to be imperfectly developed; 
the eruption may, under these circumstances, bear a close 
resemblance to the macular syphiloderm.* Here the pre- 
monitory symptoms, together with the absence of all itching 
about the eruption, also point towards syphilis. Upon close 
inspection, however, the hemorrhagic character of the lesion 
may always be detected. If seen before the appearance of 
the eruption, the disease may readily be mistaken for rheu- 
matism. 

Purpura Hemorrhagica — Laxd Scurvy — Morbus Macu- 
losus Werlhoffii. — This form usually begins with premoni- 
tory symptoms of a decided character, consisting of marked 
debility, loss of appetite, languor, headache, and feelings of 
general distress. The spots first make their appearance upon 
the limbs, extending thence rapidly to the trunk and upper 
extremities. Their advent is commonly sudden. They are 
usually in great numbers. In size they vary from a small 
coin to the palm of the hand; not infrequently two or more 
coalesce and form large, irregularly -shaped patches. A 
variety of sizes and shapes are usually encountered. Si- 
multaneously with the cutaneous lesions, or later, a general 
hemorrhage from other portions of the body, particularly the 
mouth, gums, nostrils, bowels, and bladder, commonly takes 
place. This may be either slight or very violent in its char- 
acter, large quantities of blood not infrequently being dis- 
charged. The constitutional symptoms of depression and 
debility are apt to continue as long as there is tendency to 
hemorrhage. 

The course and duration of the disease are variable; it may 
continue for days and weeks in the form of relapses, or it 



* See a paper by the author, in the Phila. Med. Times, vol. iii. p. 545, 
1873. For a report of eases of this form of purpura, see an interesting article 
by Dr. Kinnicutt, of New York ; Archives of Dermatology, vol. i. p. 193. 



PURPURA. 333 

may terminate completely within a week or a fortnight. It 
is a serious disease, and may end fatally. The hemorrhage 
may cease suddenly or by degrees. It is encountered in 
both children and adults, although more frequent in the 
latter. It occurs in the strong and properly cared-for as 
well as in the weakly and improperly fed. 

Purpura hemorrhagica differs from scurvy, the disorder 
to which it bears most resemblance, in important particu- 
lars. Purpura is commonly observed in those who have not 
been subject to the peculiar influences which give rise to 
scurvy, namely, bad hygiene, improper diet, and the want 
of vegetable food in particular. In purpura the premonitory 
symptoms are not always of a distinctive character, and may 
at times even be altogether absent ; in scurvy they are inva- 
riably present, and constitute quite a pathognomonic group, 
consisting of absolute weakness and general debility, im- 
paired circulation, tumefaction of the gums, with bleeding 
and looseness of the teeth. Purpura is apt to announce its 
presence suddenly ; scurvy always slowly. 

Pathology. — An alteration of the blood in purpura in all 
probability exists, although concerning the nature of this 
change nothing definite can be stated. The fluid is quite 
suddenly extravasated into the cutaneous tissues, and finds 
its way into the various layers and structures; at one time 
having its chief seat in the tissue of the corium itself or 
subcutaneous connective tissue, at another time about the 
glands and follicles; it may be superficial or deep. The 
blood is usually dark in color, and does not incline to 
clot. According to % the amount of blood extravasated and 
the permeability of the tissues, will the spots be small or 
large, circumscribed or diffused, roundish or irregular in 
shape, and otherwise peculiar. The process is a simple one, 
unattended by symptoms of inflammation or by marked 
subjective symptoms; very frequently it takes place un- 
awares to the patient. 

The blood once out of the vessels, acts as a foreign body 
in whatever structure of the skin it may chance to be, and 
can only be removed by resorption. The process is a slow 
and gradual one, the fluid, and more particularly its coloring 



il 



334 HEMORRHAGES. 

matter, undergoing various changes, as seen in the variety 
of colors — yellow, green, blue, purple, etc. — which the spots 
from time to time assume in the course of their decline. 
Sooner or later, in the course of weeks or months, the tissues 
gradually return to their normal state. 

Treatment. — The plan of treatment in purpura must be 
adapted to the apparent requirements of the case. Inasmuch 
as the causes producing the disease often appear to be differ- 
ent in their nature, so will the general treatment call for more 
or less modification. The diet should always receive careful 
attention, and should consist of the most nutritious articles, 
with as much variety as possible. If the hemorrhage be at 
all extensive, rest in the horizontal position is of the utmost 
importance; if slight, as often is the case in purpura sim- 
plex, it is not of such importance. 

In purpura simplex, the preparations of iron, quinine, and 
the mineral acids, together with frictions and cold baths, 
are generally beneficial. Purpura rheumatica calls for par- 
ticular attention to hygiene and diet; abundance of fresh 
air, change of occupation, the best of food, including stimu- 
lants and malt liquor, and regulation of the important func- 
tions of the economy, are to be prescribed to suit the demands 
of the case. 

Purpura hemorrhagica, usually an alarming and at times 
a very serious or even fatal disorder, calls for prompt treat- 
ment. Rest in bed is to be enjoined upon the patient. 
Quinine, iron in large and often-repeated doses, and the min- 
eral acids, are the remedies usually found to be of the most 
benefit. Ergot has recently been employed with good result. 
Cases are reported by Lane* and Minich,f in which hypo- 
dermic injections of one grain of ergotin promptly relieved 
the disorder. Oil of turpentine, and astringents, as the 
acetate of lead with opium, may also be mentioned as reme- 
dies enjoying reputation in the treatment of this form of 
purpura. 

The external treatment should consist of ablutions with 



* British Medical Journal, Sept. 5, 1874. 
f Philadelphia Medical Times, May 8, 1875. 



PURPURA. 335 

astringents in solution, as alum, tannic acid, vinegar, and 
the like. Ice-water, applied frequently to the parts, is per- 
haps one of the best local remedies; ice itself may also be 
used. Enemata of ice-water are useful where there is hem- 
orrhage from the bowels. Pieces of ice may also be taken 
into the mouth, and allowed to enter the stomach whole, in 
cases of hemorrhage from the alimentary canal. 

Prognosis. — This must vary not only with the variety of 
the disease, but also with the case. In purpura simplex the 
prognosis is always favorable as to ultimate recovery, al- 
though restoration to health may be slow. The same may 
be said of purpura rheumatica, although this form is apt to 
be stubborn, and to prolong its course indefinitely by fre- 
quent relapses. In purpura hemorrhagica the prognosis 
should always be extremely guarded, for the disease is not 
only a serious one, but treacherous as well; it is impossible 
to predict what course it will pursue. 

ILematidrosis. — This disease, known also by the names 
hsemidrosis, ephidrosis cruenta, and bloody sweat, consists 
in the appearance at the outlets of the excretory ducts of 
the sweat glands of a reddish fluid containing blood. It 
is usually in small quantity and localized, and oozes forth 
upon the surface of the skin without giving rise to any lesion 
of the epidermis. 

It is to be considered as a cutaneous hemorrhage, which 
takes place about the sweat glands and empties itself through 
the sweat ducts. It is caused by rupture of the capillaries 
of the sudoriparous glands. 

It is a very rare disorder. An exceedingly interesting case 
has recently been reported by Dr. Hart.* The affection 
has been observed most frequently in young women whose 
menstruation was imperfect, and in these instances is to be 
regarded as vicarious menstruation. The exciting causes 
which may produce it are terror, anger, and unusual nervous 
strain. The fluid poured out is noted to consist largely of 
blood. The treatment is that of purpura. 

* Richmond and Louisville Med. Jour., Jan. 1875, p. 98. 



CLASS "V. 
HYPERTROPHIES. 

A number of diseases naturally group themselves into this 
class. They are characterized by an increase of the elements 
of the normal tissues of the skin. The various structures 
which constitute the integument are all subject to hyper- 
trophy, the process either confining itself to one tissue or 
attacking several or all of the tissues simultaneously. The 
diseases may have their seat exclusively in the epidermis, 
as in chloasma and callosity, or they may involve both epi- 
dermis and papillary layer, as in ichthyosis and wart. In 
other cases the corium is the chief seat of the process, as, 
for example, in elephantiasis Arabum. The hair and nail 
also suffer. 

The hypertrophies are, with several exceptions, character- 
ized by the absence of inflammatory symptoms. In the ma- 
jority of instances they give rise to no serious inconvenience, 
and in these cases are to be viewed in the light of deformi- 
ties. Their course is slow. They may continue years or a 
lifetime. They may be congenital or acquired ; the greater 
number are acquired. The pathological features of hyper- 
trophy have been already referred to in the consideration of 
the general pathology of the skin. 

LENTIGO. 

Syn. Freckle; Germ., Summersprosse ; Fr., Lentigo. 

Lentigo consists in a pigment deposit, characterized by 
small, pin-head or pea sized, yellowish or yellowish-brown 
spots, occurring for the most part about the face and the 
backs of the hands. 

Symptoms. — The affection varies exceedingly in the degree 

336 • 



LENTIGO. 337 

of its development, consisting at times of only a few scat- 
tered spots ; commonly, however, they are present in large 
numbers. The lesions are usually small, varying in size 
from a pin-head to a split pea. They are roundish, or ir- 
regularly shaped; at times their outline is angular. They 
are either isolated, in which case they are often conspicu- 
ous, or they are aggregated and incline to coalesce ; they 
assume no regularity of distribution, but show themselves 
symmetrically. Their color varies from pale yellow to 
yellowish brown. They always have a decidedly dirty look. 
When in great numbers and crowded together, this aspect 
is very marked. Their common seat is the face, especially 
over the cheeks ; they appear also very frequently upon 
the backs of the hands and arms. Other regions may also 
be attacked, more often, perhaps, than is ordinarily sup- 
posed. They are unattended by itching or other subjective 
symptom. 

Persons of all ages, from childhood to old age, are liable 
to them; they are not seen, however, in very young chil- 
dren; rarely before the third year. They are common to 
both sexes. They usually manifest themselves in those of 
light complexion, and indeed are rarely absent in red-haired 
subjects; but they are also met with in those with dark 
complexions. Their course is chronic, lasting for years or 
a lifetime. They ordinarily make their appearance in the 
summer season, very often quite suddenly, and continuing 
through the season fade somewhat away, but not com- 
pletely, with cold weather, to return the following season. 
As the individual advances in years they are apt to disappear 
and remain away permanently. 

Etiology. — The causes which produce them are by no 
| means understood. It is well known that they are always 
more marked during the summer season, and especially 
after exposure to the rays of the sun ; but exactly how much 
influence this luminary possesses in calling them forth has 
not been as yet satisfactorily determined. Hebra has par- 
ticularly called attention to the fact that they not infre- 
quently appear upon parts of the body which are rarely, if 
ever, exposed to the light or sun ; as, for example, the back, 

22 



338 HYPERTROPHIES. 

buttocks, and penis.* It may be stated, then, that other 
causes, of an internal nature, are to be regarded as giving 
rise to the affection ; the sun, in the majority of cases, may 
be considered as the exciting cause. 

Pathology. — In anatomical structure the freckle is found 
to consist of a circumscribed, increased amount of normal 
pigment. It differs from chloasma only in the peculiar form 
and size of the lesion. 

Treatment. — The remedies which are used for removing 
"these blemishes are the same as those employed in the 
treatment of the more serious disfigurement chloasma, to 
be referred to presently. 

CHLOASMA. 

'Chloasma is a pigmentary affection, consisting of variously 
-sized and shaped, more or less defined, smooth patches, or 
of a discoloration, yellowish, brownish or blackish in color, 
occurring for the most part about the face and trunk. 

Symptoms. — The surface of the skin is observed to be un- 
altered in structure, the affection being one simply of color- 
ation. The patches may be of any size, from a coin to the 
hand or larger; they may likewise be of any shape, but are 
-ordinarily roundish or oval, and usually possess a tolerably 
sharp line of demarcation. They have a yellowish or 
•brownish, muddy, dirty color; they may even be blackish 
(melasma, melanoderma). Chloasma may also show itself 
over the whole surface in the form of a universal discolor- 
ation, variable as to color; this is observed at times in the 
course of certain diseases of internal organs. 

The chloasmata may be divided into those which are idio- 
pathic and those which are symptomatic. Under the first head 
are to be included all those forms of pigmentation acquired 
through external agencies, among which may be mentioned I 
the condition resulting from constant and long-continued 
scratching, which is practised in the course of certain dis- 
eases of an itching character, as in eczema and phtheiriasis. 

* I have quite recently had the opportunity of seeing a case in which 
they occurred upon these regions. See also Hebra's Atlas of Skin Diseases, 



CHLOASMA. 339 

Chemicals and various medicinal substances, as, for ex- 
ample, blisters, also produce more or less pigmentary de- 
posit. Heat, especially in the form of the rays of the sun, 
is a well-known cause of discoloration. When the action of 
these agents is kept up, the result is apt to be quite lasting. 

Belonging to the symptomatic group, we find the disorder 
known as chloasma uterinum, as well as those discolorations 
which occur in connection with certain general diseases ; 
in these latter cases the pigmentation is apt to be diffused 
over the whole surface. The peculiar bronzing of the skin 
found in Addison's Disease, the abnormal hue of the skin 
in carcinoma and in certain other grave disorders, may be 
referred to as striking instances. 

Chloasma Uterinum. — This variety consists in the pres- 
ence of one or several patches of pigment deposit, appearing 
usually about the forehead; they are also seen upon other 
parts of the face, and upon the trunk about the region of the 
nipple and abdomen. The condition is ordinarily observed 
in the form of a more or less continuous patch, involving the 
whole forehead, beginning just below the roots of the hair 
and terminating above the eyebrows, extending transversely 
from temple to temple. The patch may have a distinct line 
of limitation, or may fade imperceptibly into the normally- 
colored skin. Occasionally the whole face is occupied by a 
diffused, blotchy discoloration, resembling a mask. The 
color of this form of chloasma varies from dirty yellow 
to brown. There is never any desquamation ; the surface 
is always smooth. It is seen from the period of puberty to 
middle age, and is caused, in the great majority of cases, by 
changes, physiological and pathological, which take place in 
connection with the uterus. Pregnancy is one of the com- 
monly recognized causes ; although other disturbances of the 
uterine function may also occasion it. It appears in single 
as well as in married women; it is, however, of comparative 
rarity in the single, and in these cases is almost invariably 
associated with either dysmenorrhea, chlorosis, anaemia, or 
hysteria. In single women it is usually encountered between 
the ages of thirty and forty. It does not show itself after the 
climacteric period in either the single or the married. 



340 HYPERTROPHIES. 

Etiology. — The causes which give rise to chloasma are 
numerous, and very different in their nature; they are to 
be considered in connection with the respective varieties of 
the disorder, which are named from an etiological stand- 
point. The causes of the more important varieties have 
been already referred to. 

Pathology. — The affection has its seat in the mucous layer 
of the epidermis. It consists in an increased deposit of 
normal pigment, which continues to be deposited so long as 
the cause which originated it is present; after this has been 
removed the pigment is reabsorbed, and the part gradually 
assumes its natural color. 

Diagnosis. — It is liable to be confounded with tinea ver- 
sicolor, on account of the similarity in the color of the 
patches; beyond this point the two diseases have nothing in 
common. The patches of tinea versicolor are usually more 
numerous than those of chloasma, and always occupy the 
trunk; this is a region seldom invaded by chloasma, except 
in the form of a general coloration. The face is the common 
seat of chloasma; tinea versicolor is never encountered here. 
The characters of the patches are very different, and if care- 
fully examined they cannot be mistaken for each other. 
Those of chloasma are always smooth, free of scale, and 
present no alteration in the texture of the horny layer of the 
epidermis; those of tinea versicolor are always more or less 
furfuraceous, which condition can be readily demonstrated 
by gently scraping the skin with the finger-nail. Chloasma 
having attained a certain size rarely extends itself; tinea 
versicolor grows perceptibly, and often rapidly, until a large 
area is covered. Chloasma is never attended by subjective 
symptoms ; tinea versicolor usually itches ; at times it itches 
to an annoying extent. 

Treatment. — Owing to the disfigurement which lentigo and, 
more especially, chloasma occasion, treatment is at times 
called for to relieve the worriment of the patient. Attention 
should be first directed to the probable or possible cause of 
the trouble, which in the case of chloasma may frequently 
be determined. The suitable remedies, depending upon the 
condition, are then to be prescribed and persevered in. 



CHLOASMA. 841 

Decided temporary benefit may be obtained from the use of 
external remedies, which are applied with a view of acting 
directly upon the epidermis, and thus destroying the accu- 
mulated pigment. Among the various remedies which have 
been employed for this purpose, corrosive chloride of mer- 
cury, ammoniated mercury, subnitrate of bismuth, and potash 
soap may be mentioned. The corrosive sublimate is the best, 
and may be used in the form of a lotion with water, almond 
emulsion, or alcohol; its strength should vary from a quarter 
grain to live grains to the ounce, according to the suscep- 
tibility of the skin, the extent of the affection, the effect 
produced, and other circumstances. I have obtained better 
results from weak than from strong preparations. A half 
grain or a grain to the ounce will in most cases be found suf- 
ficiently strong. A lotion containing a half grain of corro- 
sive sublimate, a half drachm of tincture of benzoin, and two 
ounces of almond emulsion is a desirable formula. Hardy 
speaks well of the following: 

R Hydrargyri Chloridi Corrosivi, gr. viiss ; 

Zinci Sulphatis, £ss ; 

Plumbi Acetatis, jss ; 

Aquae, f^iv. 
M. — Sig. Lotion. Apply morning and evening. 

For the rapid removal of pigment patches the following 
method, suggested by Hebra, may be employed. A solution 
of corrosive sublimate, &ve grains to the ounce of alcohol 
or water, is applied continuously to the patch by means of 
compresses saturated with the fluid. The cloths being once 
placed upon the skin are to be kept moist by the addition 
of the fluid from time to time, and are to be retained in 
position for about four hours, when the skin will be found 
to be blistered. The roof of the blister is to be carefully 
removed and the surface dressed with starch powder. The 
newly-formed epidermis will be devoid of pigment. The 
relief, however, is not apt to be permanent, the discolora- 
tion usually returning in a variable time. 

Ointments are also employed with advantage. Sulphate 
of zinc, from twenty to forty grains to the ounce of simple 
ointment, may be used in this manner; also the ointment of 



342 HYPERTROPHIES. 

the nitrate of mercury, from one to two drachms to the ounce 
of simple ointment. An ointment composed of two drachms 
each of ammoniated mercury and subnitrate of bismuth to 
half an ounce of simple ointment is favorably spoken of by 
Neumann and others; my experience with it has not been 
very satisfactory. 

NJEVTJS PIGMENTOSTJS. 

Si/n. Naevus Spilus ; Pigmentary Mole: Germ., Pigmentmal ; Flecken- 
mal : Fr., Naevus Pigmentaire. 

Pigmentary nsevus may consist simply of a circumscribed 
deposit of pigment in the skin, without hypertrophy of the 
connective-tissue elements or of the hairy system; or, in ad- 
dition to the excess of pigment there may be hypertrophy of 
all the cutaneous structures, especially the hair. 

Naevi vary greatly as to size and shape; they may be small, 
the size of a split-pea or bean, or large, covering a consider- 
able surface. In shape they are usually roundish or oval; 
they may, however, be irregular in outline. They are more 
or less deeply pigmented, varying in color from yellow to 
brown and black. They are flat, on a level with the sur- 
rounding skin, or more or less raised; their surface is either 
smooth or uneven and furrowed. Occasionally it is rough 
and warty, when the growth is called xjevus verrucosus. 

They may or may not possess a growth of hair; very 
frequently they are without hair, while in other cases they 
exhibit an abundant growth of hair, which may be either 
of the nature of lanugo or short and bristly. When the 
naevus is hairy, it is termed x.evus pilosus. 

Pigmentary nsevi may be single or multiple. They occur 
upon various parts of the body, but are chiefly encountered 
upon the trunk, and more particularly the face, neck, and 
back. They are met with in both sexes. They may be con- 
genital or acquired ; they are usually acquired. According to 
Ilebra, congenital pigmentary moles, i.e., existing at the time 
of birth, are of rare occurrence. The small, flat, and smooth 
pigmentary nsevi without hair, seen so commonly upon the 
trunk, are almost invariably acquired during the life of the 
individual. Having attained a certain size, which seldom 



CALLOSITAS. 343 

exceeds that of a coffee grain, to which they frequently bear 
a resemblance in both shape and color, they do not incline 
to grow larger, but remain for a long time without under- 
going change; at times, it is said, they fade in color. On 
the other hand, the larger, raised, uneven and hairy nsevi 
are usually congenital ; they are permanent growths, and 
may increase in size. 

In regard to the deposit of pigment, the results of my ex- 
aminations agree with those of Simon.* The coloring mat- 
ter, consisting of pigment cells and granules, has its seat in 
the deeper strata of the mucous layer of the epidermis, and 
is seen to be accumulated in quantity between the papillae, 
as in the case of the skin of the negro. 

Pigmentary moles may, unless extensive, be removed by 
means of the knife or with caustics; when they are small 
and fiat, they may be successfully operated upon with a 
solution of caustic potassa. 

CALLOSITAS. 

Syn. Tyloma ; Tylosis ; Callus ; Callosity. 

CALLOSITAS CONSISTS IN THE FORMATION OF A nARD, THICKENED, 
HORNY PATCH OF SKIN, VARIABLE AS TO SIZE AND SHAPE, WHITISH 
OR YELLOWISH IN COLOR, UNATTENDED BY PAIN, OCCURRING FOR THE 
MOST PART ABOUT THE HANDS AND FEET. 

Symptoms. — The skin is seen to be greatly increased in 
thickness, and to present a firm, dense, more or less circum- 
scribed structure. The degree of hardness varies consider- 
ably, although usually it may be likened to that of horn. 
The patches are commonly the size of a coin, are apt to be 
roundish in shape, and possess a variable amount of elevation 
above the surrounding skin. In color they are yellowish, 
grayish, or whitish ; this, however, is always influenced by 
the amount of friction to which the part is subjected, and 
the occupation of the patient. 

Callosities usually have their seat upon the palms, fingers, 
soles, and toes, and more particularly about parts exposed to 

* Die Hautkrankheiten durch anatomische Untersuchungen erlautert. 
Berlin, 1851, p. 254. 



344 HYPERTROPHIES. 

pressure. They are frequently encountered upon the hands 
of mechanics and others who use tools; shoemakers, smiths 
of various kinds, and carpenters are particularly subject to 
them. They are seen also upon the fingers of violin and harp 
players. Upon the feet they occur for the most part about 
the soles, particularly about the ball of the great toe and 
upon the side of the little toe. These formations may 
remain unchanged for a long time, or they may undergo 
spontaneous involution as soon as the cause has been re- 
moved. Their course will depend upon their cause and its 
continuance. Their development is always a gradual one. 
Inflammation, occasionally terminating in an abscess, may 
now and then accompany them; this condition, however, is 
to be regarded as the result of long-continued and excessive 
friction or pressure. 

Etiology. — They are, in the great majority of instances, 
caused by external influences; at times, however, they ap- 
pear to be developed independently of any exciting or 
external cause. Usually they will be found to depend upon 
the continued application of pressure or friction, as in the 
case of the hand of the mechanic, the result of his tools; 
or, if upon the foot, they will be noticed to result from the 
wearing of ill-fitting shoes, or simply from unusual walking. 
They are commoner in men than in women, and may occur 
at any age, although they are more often encountered in 
middle and old a^e. 

Pathology. — The patch of callus is a simple structure, made 
up of numerous layers of epidermis, which have accumulated 
one upon the other. A transverse section, according to 
Simon,* shows it to be a hypertrophy of the horny layer 
only, the mucous layer as well as the corium remaining 
normal. The cells of the epidermis become so closely 
packed as often to simulate horn substance. 

Treatment. — When the callosity is a source of inconvenience 
it may be best removed by means of the knife. The part 
should be well soaked for some time in warm water, when it 
will become more or less softened, and will permit of being 



* Loc. cit., p. 29. 



clavus. 345 

pared or scraped off, layer by layer, with a sharp knife. The 
process is to be repeated from time to time. In some cases 
a poultice will serve to macerate the outer layers more 
effectually than water. Caustic potash solution in varying 
strength, suitable to the part to be attacked, will also prove 
serviceable ; it is, however, always to be employed cautiously, 
lest it work its way down and destroy the papillary layer, an 
accident to be avoided. 

^Vhere the formation is the result of the occupation it is not 
advisable to remove it ; not infrequently it ceases after a time 
to be produced, and in this event disappears spontaneously. 

CLAVUS. 

Syn. Corn ; Genn., Leichdom ; Hlihnerauge : Fr., Cor. 

Clavus is a small, circumscribed, usually flat, deep-seated, 
more or less horny formation, painful upon pressure, situ- 
ated for the most part about the toes. 

A corn usually presents the general outward appearance 
of a callosity; it is made up exteriorly of thickened skin, is 
polished upon its surface, and has a hard, horny feel. On 
the other hand, it may be soft, possessing features similar to 
those of the wart. It is always rounded and more or less 
circumscribed; in size it varies somewhat, but is usually 
as large as a split pea. It is painful upon pressure, and 
very frequently is accompanied by shooting sensations in- 
dependently of pressure. If the cause which has occa- 
sioned the corn be kept up, inflammatory symptoms may 
develop. 

The common seat for corns is upon the outer surfaces of 
the little toes; they also occur between the toes, and upon 
the soles of the feet. Existing between two toes, the corn 
is accompanied by more or less maceration, and appears as 
a soft, spongy formation, which receives the name of soft 
corn in contradistinction to the hard corn. One, two, or a 
number of corns may be present, in which case they interfere 
greatly with walking or even standing. 

Etiology. — They are the result either of continued press- 
ure or friction, and in the vast majority of cases may be 
referred to improperly-fitting and tight shoes. 



346 HYPERTROPHIES. 

Pathology. — The corn is made up of a circumscribed, ex- 
cessive development of the epidermis, of the same character 
as that observed in callosity, and of a central portion or 
core. The latter extends quite deeply into the tissues, in 
the form of an inverted cone, the base being directed out- 
wards, and appearing upon the surface as a round spot. 
It consists of a whitish, opaque, firm, tenacious body, with 
its apex resting upon the papillary layer of the corium. In 
structure it is composed of epidermic cells, arranged in con- 
centric lamina?. One or more cores may exist. The corium 
beneath may be either atrophied or hypertrophied. The 
pain attending corns is produced by the core pressing upon 
the true skin, causing more or less irritation of the nerve 
filaments of the papillae. 

Treatment. — If the cause be removed, the treatment of 
corns is sufficiently simple. On the other hand, if improperly- 
fitting shoes and other causes be persisted in, much delay 
and difficulty may be experienced in relieving the condition. 
If the patient is obliged to walk much, the corn should be 
protected by a piece of cut felt. The foot should be fre- 
quently soaked in warm water, after which the outer layers 
will be macerated, and may then be removed by scraping 
or picking with a pointed knife. A bread and milk poul- 
tice, applied to the part by a bandage before retiring, and 
kept on all night, will relieve the corn as effectually as any 
of the more noted nostrums. This treatment, repeated for 
several nights in succession, will usually soften the growth 
to such an extent that it may readily be extracted from its 
bed without pain. 

Various plasters are recommended, most of which consist 
of resin, galbanum, or pitch plasters, together with acetic 
acid, subacetate of copper, chloride of ammonium, carbon- 
ate of potassium, and like substances. Nitrate of silver, in 
solid stick form, may often be used with advantage after 
the corn has been sufficiently softened; it will also be found 
useful in soft corns occurring between the toes. A coating 
of flexible collodion may be employed with benefit in pain- 
ful soft corns. Potassa with water or alcohol, a drachm to 
the ounce, may be applied where the epidermis is hard and 



CORNU CUTANEUM. 347 

thick; the application should be made with care, and only 
to the part to be acted upon. 

CORNU CTJTANEUM. 

Syn. Cornu Human um : Cutaneous Horn; Horny Excrescence ; Horny 
Tumor: Germ., Hauthorn : Fr., Production Cornee; Corne de la Peau. 

Cornu cutaneum is characterized by the development op a 
true horny formation arising from the skin, variable as to 
size and shape. 

Symptoms. — When fully developed the excrescence is seen 
to be a veritable horn, differing but slightly, if at all, from 
that found normally upon the lower animals. It is a solid, 
hard, dry formation, and is observed to have a more or less 
laminated, wrinkled, roughened, uneven surface. 

In form cutaneous horns are usually elongated and round- 
ish, or conical; occasionally they assume a flattened form, 
when they are but little elevated above the surrounding 
skin. They vary exceedingly as to shape, but are apt to be 
crooked, twisted, and bent ; they are rarely straight. They 
terminate either pointedly or with a blunt end. Their color 
is usually grayish; it may also be either yellowish, brown- 
ish, or blackish. 

They grow to all sizes, varying from a few lines to many 
inches; their diameter is always greater at the base than at 
the free extremity. They possess a concave or flattened 
base, which rests directly upon the skin, from which they 
spring abruptly. The tissues about their bases may be 
either normal or somewhat raised; at times there is an areola 
and a certain amount of inflammation, which may be followed 
by suppuration. 

Horns are usually solitary; occasionally, however, they 
are multiple. They may appear upon any region of the in- 
tegument, but are more common about the face and scalp. 
They seldom make their appearance before the age of forty 
or fifty ; they have, however, been met with in the young. 
As a rule, they are unattended by pain ; if knocked or dis- 
turbed they may subsequently be accompanied by consider- 
able uneasiness and pain about their bases. Their course 
is slow, growing with variable rapidity until they arrive at 



348 HYPERTROPHIES. 

a certain size, when they not infrequently become loose and 
drop off, leaving an open, ulcerating base. When this takes 
place they are very liable to be reproduced. 

Etiology. — The causes are not satisfactorily determined. 
The affection is a rare one. A number of reported cases 
have been collected by Lebert,* Wilson, f Bergh,J and 
Damon. § An interesting case, with photograph, has been 
reported by Dr. W. H. Pancoast, of this city.|| 

Pathology. — According to Lebert,1f cutaneous horns spring 
from the deeper strata of the mucous layer of the epidermis, 
and consist in a hyperplastic growth of these cells. Inas- 
much as this layer is present not only immediately above the 
papillae of the corium, but also as a lining membrane in the 
follicles and glands, it will be seen that the disease may start 
in these latter structures quite as readily as from the free 
surface of the epidermis. Microscopic examinations, by the 
same observer, show longitudinal sections to be made up of 
a mass of "small columns, rods, or palisades lying close to 
one another, and so intimately united by a connecting sub- 
stance as to appear blended into a homogeneous mass. The 
individual columns have a striped, shreddy appearance, and 
are made up entirely of epidermic cells arranged upon one 
another in an imbricated manner." Transverse sections 
show roundish spaces, concentrically stratified, between the 
layers of which exist irregularly-placed epidermic cells, which 
are to be viewed as the connecting substance referred to in 
considering the longitudinal sections. The cells, as might 
be expected, are for the most part without nuclei; they 
always belong to the epidermic variety. Both Lebert and 
Virchow have demonstrated the presence of bloodvessels 
in the bases of horns. The character of the cutaneous base 
from which the excrescence proceeds is found to vary. 



* Ueber Keratose oder die durch Bildung von Hornsubstanz erzeugten 
Krankheiten und ihre Behandlung. Breslau, 1864. 
f Medico-Chirurgical Transactions, 1844, vol. xxvii. p. 52. 
+ Archiv fur Derm, und Syph., II. Heft, p. 185, 1873. 
g Structural Lesions of the Skin. Philadelphia, 1869. 
|| Photographic Beview of Medicine and Surgery, vol. i. No. 1, 1870. 
\ Loc. cit., p. 76. 



VERRUCA. 349 

Treatment. — After the horn has been detached from the 
skin, it is a very necessary part of the treatment to destroy 
the base by means of some caustic, for which purpose chloride 
of zinc or caustic potash may be used. If there be a tendency 
to reproduction, the operation should be repeated. 

VERRUCA. 
Sf/n. Wart: Germ., Warze; Fr.j Yerrue. 

Verruca is a hard or soft, rounded, flat, or acuminated, 
circumscribed, papillary formation, variable as to size. 

Symptoms. — AVarts present themselves in a number of 
forms. They are so different as to require separate descrip- 
tions. 

Verruca Vulgaris. — This is the ordinary wart, commonly 
met with on the hands. It consists of a small, circumscribed, 
usually split-pea sized and shaped, elevated growth, with a 
broad base, seated securely upon the skin. It is quite firm 
in consistence, and very often hard, with a horny exterior. 
The surface is observed to be either smooth or rough, and to 
be studded with a number of minute elevations, — hypertro- 
phied papilla?. These may be so irregularly developed as to 
give it a divided or lobulated appearance. The color is 
either that of the surrounding skin or darker; at times it is 
yellowish, brownish, or blackish. 

One, several, or great numbers of these warts may exist ; 
they are apt to appear in groups, and very commonly are 
in such close proximity as to touch and press upon one 
another. Their usual seat is about the hands, especially 
the fingers; they may, however, show themselves upon any 
region. 

Verruca Plana. — This differs from the above-mentioned 
variety in being perfectly flat and broad in form. They are 
usually the size of a small finger-nail, and are but slightly 
elevated above the level of the surrounding skin. They 
occur either singly or in numbers, and are seen most fre- 
quently upon the back, especially in elderly people, when 
they are apt to be brownish in color, and are observed 
to be more or less sebaceous in character. 

Verruca Filiformis. — This variety assumes the shape of a 



350 HYPERTROPHIES. 

small, thin, conical, or thread-like formation, usually about 
an eighth of an inch in length. These little growths may 
appear either singly or in groups ; rarely, however, in 
numbers. They are chiefly encountered on the face, on the 
eyelids, and on the neck. 

Verruca Digitata. — The formation here, as in the case of 
the flat wart already referred to, consists of a slightly elevated, 
broad excrescence, varying in size from a split pea to a large 
finger-nail, and marked by a number of digitations coming 
out from its border; these are often greatly developed, and 
give to the growth an appearance resembling a crab. This 
form is commonly seen upon the scalp ; they are often 
present in great numbers. 

Verruca Acuminata.* — This variety consists of one or 
more groups of acuminated or irregularly-shaped elevations, 
usually so closely packed together as to form a more or less 
solid mass of vegetations. The individual prominences vary 
considerably as to form; they tend to be pointed or tufted, 
but they may also be club-shaped, and in some cases exist 
as thick, short, fleshy excrescences, giving the growth the 
appearance of granulation tissue. They may be either sessile 
or pedunculated. In color they are pinkish or reddish; at 
times they are bright red, in other cases purplish, the shade 
depending upon the degree of vascularity, and the region in 
which they happen to exist. They occur for the most part 
about the genitalia of either sex, more particularly about the 
penis and labia. Upon the penis they usually spring from 
the glans and the inner surface of the prepuce ; upon the 
female they are apt to start from the inner surfaces of the 
labia and from the vagina. They are also encountered about 
the anus, mouth, axillae, umbilicus, and toes. According to 
the region in which they are present, will they be dry or 
moist; about the genitalia, a yellowish, puriform secretion 
usually covers their surface, due to friction and maceration, 
which, owing to the heat of the parts, rapidly decomposes, 



* Termed also Pointed Wart, Moist Wart, Fig Wart, Pointed Condyloma, 
Cauliflower Excrescence, Verruca Elevata, Venereal Wart; Germ, Spitze 
Condylom; Fr., Vegetation Dermique. 



VERRUCA. 351 

producing a highly offensive substance. Crusts, made up of 
secretion and blood, are also not infrequently present. The 
odor from these condylomata is usually of a remarkably 
penetrating and disgusting character. 

They may attain a large size ; not uncommonly they grow 
as large as a hen's egg, and at times to the size of a fist. 
According as they happen to be arranged and distributed, 
they present different appearances ; they have been aptly 
compared to a head of cauliflower, to a cock's-comb, to fungi, 
to raspberries and other forms of vegetation. 

Their development is rapid; very frequently they attain 
considerable size in the course of a few weeks. They always 
appear as a vigorous and luxuriant growth, tending to in- 
crease in size and to multiply; without interference they 
may assume large proportions and continue for an indefinite 
period. They are met with in both men and women, and are 
usually encountered in young people. 

Etiology. — The causes which give rise to warts are obscure. 
The various influences which are popularly assigned as causes, 
most of which are widely different in their nature, are, it need 
scarcely be stated, incapable of producing the disease. They 
occur in both sexes, and are more common in the young than 
in the old; they are frequently encountered in children. 

In regard to the acuminated variety, or pointed condylo- 
mata, it is well known that they are often caused by the 
irritating secretions of venereal disease, more especially gon- 
orrhoea. They are never a manifestation of constitutional 
syphilis. 

Pathology. — The anatomy of warts differs somewhat ac- 
cording to the variety, but in all forms there exists, as a 
basis, a connective -tissue growth, from which papillary 
hypertrophy, to a greater or less extent, takes place. The 
interior of the formation is always supplied by one or more 
vascular loops, from which the structure obtains its vitality. 
In the common, hemispherical wart, the papillae become 
greatly thickened and elongated, and are covered with a 
hypertrophic layer of epidermis, which gives it the hard, 
horny exterior. 

The pointed warts, or condylomata, are exceedingly vas- 



352 HYPERTROPHIES. 

cular, and are made up chiefly of connective-tissue elements, 
which form a mass of firm consistence. The papillae are 
enormously hypertrophied and are covered with an exuberant 
and extensive mucous layer, the cells of which are highly 
developed. The horny layer is seldom formed to any extent ; 
this is found to vary, however, according to the locality in 
which the growth occurs. 

Treatment. — Local remedies alone are of value in removing 
these growths. Excision, by means of the knife or scissors, 
in many instances affords the most satisfactory results, the 
operation, as to the manner of cutting, varying somewhat 
with the form of wart under consideration. Many of the 
smaller formations are best removed by a pair of curved 
scissors, their bases being touched with the nitrate of silver 
stick. The ligature and the galvano-caustic wire may be 
advantageously employed where the growth is of some size 
and liable to be attended with hemorrhage, as in cases of 
pointed warts about the genitalia. Acuminated warts of 
venereal origin may be successfully treated by washing the 
parts with the liquor sodas chlorinate, and afterwards dusting 
with calomel ; or, with nitric or chromic acid. 

Warts may also be treated very satisfactorily by the appli- 
cation of various caustics, among which potassa, nitrate of 
silver, acid nitrate of mercury, chloride of zinc, nitric acid, 
chromic acid, hydrochloric acid, and acetic acid may be 
especially mentioned. Caustic potash, nitrate of silver, and 
chromic acid, in solution, will be found the most useful ; in 
the case of the two latter substances, repeated applications 
will often be required. In selecting a remedy, the variety 
and size of the growth, as well as the locality in which it 
occurs, should be considered. The strength of the solution 
is to be regulated according to the nature and exterior cov- 
ering of the wart. In making the application of fluid sub- 
stances, care should be exercised to protect the adjacent 
healthy skin ; a layer of soft wax placed immediately around 
the growth will prevent the caustic from attacking the sound 
skin. 

Prognosis. — This is always favorable. If properly destroyed, 
they show no tendency to recur. Where they are very 






ICHTHYOSIS. 353 

numerous or of great size, it is advisable not to undertake 
the removal of the whole mass at one time. Hemorrhage 
should always be guarded against. 

Papilloma Cutis. — Under this head may be placed those 
cases which have been described with various names by 
Beigel,* Bergh,f Roser,t Weil,|| Charpy,§ and Gerhardt.l 
The true papilloma of the skin, of which Weil's case may 
be taken as an example, is an inflammatory formation or 
tumor, variable as to size, made up of a growth very similar 
to that of the acuminated wart, or condyloma. It consists 
of a fiat or raised, cauliflower excrescence, inflammatory in 
character, reddish or bluish in color, showing great hyper- 
trophy of the papillae. Fissures and sinuses are apt to be 
present, which secrete a yellowish, puriform fluid. The 
course of the tumor is usually rapid, as in the case of the 
acuminated wart. The formation may appear upon any 
region of the body, and at any time of life; it is of a benign 
nature, and is not due to syphilis. 

ICHTHYOSIS. 

Syn. Xeroderma ; Xeroderma Ichthyoides ; Ichthyosis Vera ; Ichthyosis 
Congenita; Fish-skin Disease; Germ., Fiscbschuppenausschlag ; Fr., Ich- 
thyose. 

Ichthyosis is a congenital, chronic, hypertrophic disease, 
usually occupying the whole surface, characterized by dry- 
ness and harshness of the skin, the formation of scales, and 
a variable amount of papillary growth. 

Symptoms.- — Two varieties of the disease are encountered ; 

* Papilloma Area-Elevatum. Virchow's Archiv, Bd. xlvi. Heft 3 u. 4, 
1869. Abstract in Amer. Jour, of Syph. and Derm., vol. i. p. 82, 1870. 

f Pessema. Archiv fur Derm, und Syph., 4 Heft, p. 578, 1870. Abstract 
in Phila. Med. Times, vol. ii. p. 247, 1871-2. 

X Das entziindliche Hautpapillom. Archiv der Heilkunde, 1866, p. 87. 

|| Das entziindliche Hautpapillom. Vierteljahresschrift fur Derm, und 
Syph. Erstes Heft, p. 37, 1874. (With chromolithograph.) 

I Lichen Hypertrophique. Annales de Dermatologie et de Syphiligraphie, 
No. 1, 1872-73. Translated in the Amer. Jour, of Syph. and Derm., vol. 
iv. p. 277. 

T[ Jahrbuch fiir Kinderheilkunde, N. P., iv. Abstract in the Amer. Jour. 

23 



354 HYPERTROPHIES. 

they are named ichthyosis simplex and hystrix. They may 
occur independent of each other or together. Ichthyosis 
varies exceedingly in the degree of its development. In 
one individual it amounts to but a slight inconvenience; in 
another it manifests itself in so pronounced a manner as to 
be the source of great discomfort and serious deformity. 

Ichthyosis Simplex. — This is the variety usually met with. 
When simple dryness and harshness only of the skin exist, 
with more or less furfuraceous exfoliation, but without the 
formation of plate-like scales, the condition is termed xero- 
derma ; this constitutes the least marked and the mildest 
type of the affection, and is of not infrequent occurrence. 

As ordinarily encountered, ichthyosis consists of an altered 
state of the skin, characterized by a harsh, dry condition of 
the whole surface, accompanied by the production of vari- 
ously sized and shaped, reticulated, fish-like scales. These 
are either small, thin, and furfuraceous, like bran, or they 
are large and thick, resembling fish scales, and are shaped 
after the normal lines and furrows of the part on which they 
happen to exist. Upon the extremities they usually form 
square, diamond-shaped or polj'gonal plates, separated from 
one another by deep furrows or lines, which extend down 
to the normal skin. The amount of scaling present will 
depend upon the age of the patient, the severity of the dis- 
ease, and the external treatment, as, for example, bathing, 
to which the skin has been subjected. If the scales be not 
removed from time to time, they tend frequently to accumu- 
late into lamina of considerable thickness. In color they 
are usually whitish, grayish, or yellowish, and very often 
have a silvery, glistening look; in other cases they are more 
or less of a yellowish olive-green ; while more rarely they 
are dark olive-green or blackish. Even in those cases where 
the affection is but slightly developed, the skin usually pos- 
sesses a dirty, yellowish tint, as though it had not been 
recently washed. 

Ichthyosis Hystrix. — This variety varies greatly as to the 
extent of its development ; it may exist in the form of one or 
more localized patches, or as a more diffused disease, involv- 
ing the greater portion of the surface in a broken, unevenly 



ICHTHYOSIS. 355 

distributed manner. It is characterized by irregularly-sized 
and shaped, ill-defined, rough, harsh, yellowish, brownish, or 
greenish patches, which are made up of enormously hyper- 
trophied, hard, more or less horny papillae. These patches, 
or areas of disease, may occur upon any part of the body. I 
have seen them upon the arms as solid, warty patches ; upon 
the back in the form of elongated, linear patches; about the 
folds of the axillse, around the neck, around the umbilicus, 
and upon other regions. Several or a number of regions 
are apt to be the seat of disease in the same patient; in other 
cases these growths appear upon, for example, an arm or the 
back only. They are usually very irregular in shape, adapt- 
ing themselves in outline to the region upon which they 
exist. They may constitute roughened, corrugated, papil- 
lary growths, or they may result in uneven, hard, horny, 
blunt or pointed, spinous, warty formations. In the latter 
case the elevations may reach several lines or more, and stand 
out from the skin like quills upon the back of a porcupine, — 
hence the name hystrix. Like ichthyosis simplex, this vari- 
ety varies materially according to the age of the individual 
in whom it is seen ; the older the patient the more highly 
developed will it usually be. Its features become more pro- 
nounced as adult age is approached. 

Ichthyosis is a disease which usually involves the whole 
surface, more or less generally, although it always manifests 
itself more markedly in certain regions; these are the lower 
extremities, from the hips down to the ankles, and the arms 
and forearms. The knees and elbows are in almost all cases 
the seat of considerable wrinkling, thickening, roughness, 
and scaliness. On the other hand, the flexures of the elbows 
and knees, as well as the axillse and the groins, seldom show 
the disease at all. The difference between the outer surfaces 
of the joints and the flexures is always striking. 

At times certain regions of the body are affected to the 
comparative freedom of other parts ; this is especially the 
case in ichthyosis hystrix, where irregularly distributed areas 
of papillary hypertrophy exist here and there in the form of 
patches. The scalp and face rarely exhibit the disease in a 



356 HYPERTROPHIES. 

marked degree. The scalp and hair, however, are usually 
dry, and the latter is more or less harsh and brittle. 

The skin of the hands and feet is always dry and wrinkled, 
the natural lines of motion being deeply furrowed. The 
hands and feet have a dry, withered feel, and are usually 
cold. The soles of the feet show marked epidermic thick- 
ening and callosities. The backs of the feet and ankles 
occasionally develop thick, bulky masses of scales, which 
assume the form of small polygonal or quadrangular plates, 
resembling in both appearance and conformation the skin 
of the alligator. These epidermic plates are at times dark 
greenish or blackish in color (ichthyosis nigricans). A 
marked case of this kind, in a young woman, has recently 
presented itself to my notice. 

Ichthyosis is always very much worse in winter than in 
summer. In the majority of cases it is only at this season 
of the year that the affection gives rise to inconvenience. It 
usually disappears more or less completely during the spring 
and summer. Even those instances in which there is marked 
papillary hypertrophy, are greatly influenced and modified by 
warm weather. 

Ichthyotic persons are noted to perspire but very slightly. 
Sensible perspiration usually takes place only from certain 
localities, as the axillae, face, palms, and soles. The increased 
activity of the sweat glands in summer, and the effect of this 
secretion upon the epidermis, produce the most beneficial 
results, relieving the patient of his disease almost entirely 
for the time. 

The course of ichthyosis is essentially chronic. It con- 
tinues throughout life, varying in its severity with the sea- 
sons. The subjective symptoms are of little importance. At 
times there is slight itching, which usually comes on when 
the skin is exposed to the air, as when the clothing is removed 
at night; it may be quite annoying. The symptom is not a 
constant one. Patients, I have noted, not infrequently com- 
plain of it in the spring of the year. 

Etiology. — "While not congenital in the strict sense of the 
term, the affection is nevertheless to be regarded as one 
which is born with the individual; it, however, does not 



ICHTHYOSIS. 357 

ordinarily manifest itself until after the first or second year 
of life. As a rule, ichthyotic subjects come into the world 
with smooth skins, and retain them without sign of deformity 
until perhaps months or one or two years have passed, when 
they begin to show symptoms of the disease. At first it 
is very slight, but year by year it becomes more marked 
until adult age is reached, when it ceases to increase in in- 
tensity, remaining in about this condition through life. 

It is hereditary in some cases, but not in all. Instances 
very often present themselves in which one or the other 
parent is similarly affected; other cases, according to my 
experience, not infrequently occur in which neither parents 
nor grandparents are found to have any trace of the disease. 
One child only out of a large family may be affected ; in 
other cases more than one may show signs of it. The parents 
of ichthyotic children are usually healthy and without con- 
stitutional vice. The subjects themselves of ichthyosis com- 
monly enjoy the best of general health. The condition, then, 
is to be considered in the light of a simple deformity, similar 
from an etiological point of view to naevi, albinism, and 
other like structural defects. It occurs in both sexes, is 
common to all races, and is found in all spheres of society. 

Pathology. — The changes which exist in ichthyotic skin 
will be found to differ materially as one form or another of 
the disease is examined. Thus, slight ichthyosis — xeroderma 
— offers an altogether different picture from the severer type 
hystrix. The disease, however, may be said, to consist in 
an excessive proliferation of the cells of the epidermis, to- 
gether with more or less hypertrophy of the papillae of the 
corium. In a section of ichthyosis of ordinary development 
the horny layer will be observed to be enormously increased 
in thickness, to be very dry and of a yellowish color; the 
mucous layer will also be seen to be greatly augmented by 
new cells. 

The papillae are longer than normal, and are infiltrated 
with cells; the vessels are also enlarged. According to 
Neumann, the sebaceous glands are unrecognizable. Xohn* 

* Archiv fur Derm, und Syph., III. Heft, p. 418, 1869. 



358 HYPERTROPHIES. 

found, in a typical case of ichthyosis hystrix, that the disease 
began in the vascular layer of corium, as proved by the ex- 
istence of the so-called exudation cells. The papillae were 
conically elongated, and widened about their bases, the en- 
largement taking place by means of a growth of new con- 
nective tissue. The mucous and horny layers were largely 
increased, and were found to be made up of a number of 
laminae. 

Diagnosis. — The features of the disease are of so peculiar a 
character that but little difficulty is experienced in arriving 
at the diagnosis. The harsh, dry, wrinkled skin, the hyper- 
trophic epidermis, the enlarged papilla?, the thin, yellowish 
scales, the deep furrows and lines, especially about the joints, 
the diffused distribution of the affection, and the regions 
particularly affected, all point to ichthyosis,, and only this 
disease. Added to these objective symptoms, the history, 
in the case of an adult, will aid in establishing the diagnosis. 
It will be distinguished from the inflammatory disorders 
which tend — as, for example, eczema — to terminate in des- 
quamation, by the absence of any history of inflammation. 

Treatment. — External treatment is alone found to be of 
service. Various internal remedies, including iron, arsenic, 
cod-liver oil, and iodide of potassium, have from time to 
time been employed, but all without benefit. Local thera- 
peutics, however, exert a favorable influence upon the affec- 
tion, and, at the present day, constitute the method of coping 
with this disagreeable trouble. Of the several remedies 
used, water is to be mentioned as being the most valuable; 
it is used in the form of baths, either simple or medicated. 
Its action upon the skin is a mechanical one, macerating 
the accumulated masses of epithelial matter and exposing 
young layers of epidermis, which are found to be compara- 
tively soft and pliable. The relief thus obtained is tem- 
porary, but, nevertheless, affords the patient ease and 
comfort for some time, and, when persevered in, may so 
modify the skin as to retard the hypertrophy. It may be 
stated, then, that the more frequently the ichthyotic patient 
bathes, and the longer he is able to remain in the water, 
the less will the deformity show itself. Vapor baths are 



LICHEN PILARIS. 359 

particularly serviceable ; also alkaline baths, containing from 
two to eight ounces of the bicarbonate of sodium to the bath. 

Soap, more especially soft soap, is an invaluable remedy ; 
it may be used either in connection with the bath, or alone, 
as a discutient, when it may be applied according to the 
following directions. A sufficient quantity is to be rubbed 
into the skin twice daily, for four or six days, during which 
period the patient is to refrain from bathing. A bath is 
first to be taken four or live days after the last rubbing, 
when, in fact, the epidermis has begun to peel off; afterwards 
inunction with a simple ointment is to be applied, in order to 
prevent Assuring of the new skin. It matters little as to the 
kind of oil or ointment used, provided it is not stimulating; 
oil of sweet almond, olive oil, benzoated simple ointment, 
glycerine, either pure or diluted with water, and vaseline, 
will be found the most valuable substances. I prefer the 
two latter. 

For the treatment of the hystrix variety, in addition to the 
general plan just described, it will be necessary to employ 
caustic applications, or at times even the knife, for the pur- 
pose of removing the horny patches of hypertrophy. 

Prognosis. — This is unfavorable as regards permanent re- 
lief. Much, however, can be done to alleviate the condition 
by advice and appropriate external treatment, but experience 
teaches that here the value of therapeutics ceases. The 
deformity, for it is to be looked upon in this light, con- 
tinues throughout life, its course changing but slightly, if at 
all, after adult age has been reached. The patient should 
always be made fully acquainted with the nature of the 
trouble. 

LICHEN PILARIS. 

Syn. Pityriasis Pilaris. 

Lichen pilaris is a hypertrophic affection, characterized 
by the formation of pin-head sized, conical, whitish, solid, 
epidermic elevations seated about the apertures of the hair 
follicles. 

Symptoms. — The disease consists essentially of an accumu- 
lation of epidermis about the openings of the hair follicles. 
The epithelial cells collect and heap up around the hairs, 



360 HYPERTROPHIES. 

forming more or less conical elevations or papules. The 
lesions are pin-bead in size, and are made up of epithelial 
structure and sebaceous matter, containing in their centre a 
convoluted or twisted hair. Each elevation is pierced by 
a hair, around which the accumulation of epidermis takes 
place concentrically, in the form of laminae. The hairs are 
either contained within the formation, and are not to be 
seen, or they protrude through the apex; very frequently 
they are broken off short at the surface, and give the papule 
a dark, central point. The elevations are raised, are whitish 
or grayish in color, and are seated upon skin which is normally 
colored or reddish. 

The skin is always dr}-, rough, scaly, and harsh, as in ich- 
thyosis ; passing the hand over the surface the elevations 
may be readily detected as minute, pointed asperities, feeling 
at times like a fine nutmeg grater. 

The usual seat of the affection is the extremities, and 
more particularly the extensor surfaces. It is ordinarily 
encountered about the thighs, and upon the arms and fore- 
arms. It is also met with on the trunk. It occurs for the 
most part in young persons of either sex, and especially in 
those who are in the habit of not bathing; I have, how- 
ever, also observed it, not infrequently, in those who used 
water freely. It varies greatly in the extent of its develop- 
ment; verj 7 often it is present as so slight a disorder as to 
escape notice. As a rule, it is unaccompanied by itching. 
Its course is chronic ; it may continue for years. Very often 
it is associated with ichthyosis. 

Diagnosis. — Lichen pilaris is to be distinguished from cutis 
anserina (goose-flesh), which it may resemble, by the perma- 
nence of the lesions. In goose-flesh the disorder is acute, 
passing away with the exciting cause; as, for example, cold 
or nervous excitement. The affection may also be mistaken 
for the miliary papular syphiloderm in its desquamating stage, 
to which it not infrequently bears a close likeness. In the 
syphiloderm, however, the lesions group, and are more solid, 
deeper seated, and less scaly in structure. Lichen pilaris is 
also to be diagnosed from lichen scrofulosus, in which dis- 
ease the papules are firmer and less scaly, and, moreover, 






SCLERODERMA. 3(jl 



incline to group. The disorder under consideration may 
also be confounded with pruritus hiemalis. 

Treatment. — The treatment consists of repeated warm or 
vapor baths, with the free use of sapo viridis, or other 
strong soap; alkaline baths are also of service. In obstinate 
cases oily and fatty preparations, as, for example, glycerine 
and vaseline, may be employed with great benefit, as in 
ichthyosis. 

SCLERODERMA. 

Syn. Sclerema ; Scleriasis ; Scleroma Adultorum ; Sclerostenosis ; Cutis 
Tensa Chronica ; Dermatosclerosis ; Germ., Hautsclerem ; Fr., Sclereme des 
Adultes ; Sclerodermic 

Scleroderma is a chronic disease, characterized by a dif- 
fuse, HARDENED, NEITHER RAISED NOR DEPRESSED, MORE OR LESS 
PIGMENTED, HIDE-BOUND CONDITION OF THE SKIN, UNATTENDED BY 
SUBJECTIVE SYMPTOMS OR ALTERATION OF SENSIBILITY. 

Symptoms. — The disease commences by an apparently sim- 
ple hardening of the integument, which is usually observed 
to increase gradually in intensity until the part becomes 
almost as hard as wood or stone. It also commouly pro- 
gresses in extent until a considerable amount of surface is 
involved. The process is accompanied neither by constitu- 
tional disturbance nor by local symptoms of an inflammatory 
nature. When the affection has become fully developed the 
skin and subcutaneous tissues are found to be immovable; 
they are absolutely hard to the touch. The skin is firm, 
fixed, and solid, as though frozen. The condition is a 
striking one, and has been variously described by writers as 
being like "leather," or "frozen without the sensation of 
cold," "hard as a board," "hide-bound," and "petrified." 

There is neither elevation nor depression of the skin, the 
parts affected being upon a level with the surrounding in- 
tegument. No line of demarcation exists about the disease; 
the transition into the healthy tissues is a gradual and im- 
perceptible one. The color of the skin varies considerably, 
there being present always more or less pigmentation ; it 
is usually yellowish or brownish, and often has a waxy 
appearance. 

The disease is apt to occupy large portions of the body, as, 



362 HYPERTROPHIES. 

for example, the greater part of one or both limbs, the trunk, 
or even the whole surface. It may attack any region ; very 
frequently it commences upon the back of the neck and 
spreads down the back. The limbs, both upper and lower 
extremities, are often the seat of the affection ; the face like- 
wise at times suffers. When upon the limbs it is usually 
symmetrical. The temperature as well as the sensibility of 
the surface remains unaltered throughout the disease. Both 
the sebaceous and sudoriparous glandular systems are like- 
wise unaffected. 

The subjective symptoms are negative, no itching or pain 
being at any time present. This remark of course does not 
apply to those cases where the joints and natural folds of the 
skin are involved ; here there is always more or less pain on 
motion. 

The course of the disease is chronic ; it continues through 
a period of years or a lifetime. In certain cases, rarely, 
however, recovery takes place spontaneously. Other cuta- 
neous diseases have been observed to appear upon sclero- 
dermic patches, for example, eczema and acne. 

Etiology. — The causes are very obscure. It may occur at 
any period of life, but is more common at middle age. It 
has been encountered more frequently in women than in 
men. The general health is usually found to be good. Rheu- 
matism, in some cases, has been noted to have preceded the 
attack. It is a rare disease.* 

Pathology. — The anatomy of scleroderma has been care- 
fully studied by F6rster,f Auspitz,J Arning,§ Neumann, || 
Kaposi,T and others, with varying results. The following, 

* Cases have recently been reported by Arnold, Amer. Jour. Of the Med. 
Sci., July, 1869; Day, Amer. Jour, of the Med. Sci., April, 1870; Piflard, 
New York Med. Gaz., June 24, 1871 ; Yan Harlingen (with an exhaustive 
bibliography), Amer. Jour, of Syph. and Derm., Oct. 1873; and White, 
Archives of Dermatology, July, 1875. 

f Wiirzburger 3Ied. Zeitschrift, 1861, B. ii. p. 294. 

% "Wiener Med. Wochenschrift, 1863 ; quoted in Xeumann's work, 3d edi- 
tion (German) p. 354. 

§ Wurzburger Med. Zeitschrift, 1861, vol. ii. p. 186. 

|| Loc. cit., 3d edition (German), p. 354. 

f Loc. cit., vol. iii. p. 119. 



SCLERODERMA. 363 

however, will represent the changes usually found. The 
epidermis remains unaltered in structure, but coutains a de- 
posit of pigment in the lower layers of the rete. The papillae 
are normal in size. Both the corium and the subcutaneous 
tissue are seen to be the seat of the disease. They are found 
to be infiltrated, greatly thickened, and to contain a marked 
increase in the connective tissue and elastic fibres. In the 
subcutaneous tissue, the fat cells are scanty and are sur- 
rounded by dense bundles of connective tissue. The whole 
cutaneous tissue is thus converted into a compact mass, made 
up of densely-packed fibres more or less interlaced and bound 
together. Concerning the vessels, which unquestionably 
play an important part in the pathology of this disease, Ka- 
posi states that he found them " diminished in calibre, and 
closely surrounded by connective tissue. In spots here and 
there, and in large tracts, the connective tissue surrounding 
both sides of a vessel appeared pushed aside from its walls 
by. small, nucleated (lymph) cells closely heaped on one 
another. By th-ese cell-masses, the vessel was increased to 
five or six times its normal breadth, as if enclosed in a cell- 
sheath. The accumulation of cells w 7 as distinctly limited, 
laterally, by a continuous fibrous border. One may say that 
the cells were accumulated in the perivascular lymph-space 
(adventitious space)." 

In summing up the facts bearing upon the nature of scle- 
roderma, the same observer is of the opinion that the disease 
consists in a diffused thickening and stasis of lymph in the 
cutis, a view which, in consideration of the clinical as well as 
pathological features, appears to me to be highly plausible. 
Kaposi further adds in explanation, "in consequence of the 
thickening of the lymph, which results, not from local con- 
ditions, but from a generally abnormal state of the nutri- 
tive processes, this stagnates in the interstices of the tissue, 
which, according to the views as to the commencement of the 
lymph-passages, are considered to be lymph-spaces. Hence 
the early, but already firm, rigid infiltration of the cutis. 
Should the flow of the lymph again become free, then, also, 
the infiltration disappears completely, and the cutis returns 
to its normal condition. Should the stagnation continue for 



364 HYPERTROPHIES. 

a longer time, then, out of the accumulated superfluity of 
nutrient material, the previously normal connective tissue is 
formed in excess, becoming denser and denser. The inter- 
stices of the tissue become narrower and narrower, and 
consequently the latter can only be infiltrated by a smaller 
quantity of fluid. The connective-tissue texture becomes 
less and less juicy, retracted, and shrunken, like all slightly- 
juicy connective tissue and cicatrices." 

Diagnosis. — Bearing in mind the peculiar characters of the 
disease, which are in most cases well marked, no trouble 
should be experienced in determining the diagnosis. The 
solidified, rigid, hard, more or less pigmented condition 
of the integument, apparently unaltered in structure, will 
alone be sufficient to distinguish it from other diseases. 

It is not to be confounded with morphoea, an affection to 
which it bears a resemblance, but from which in reality it 
differs very materially both clinically and pathologically. It 
may be stated that, among other differences, in scleroderma 
the disease is always of a diffused character, while in mor- 
phoea it is limited and more or less circumscribed. Absolute 
hardness of the skin is from the first the most prominent 
feature of scleroderma; in morphoea there is no marked 
hardness, except in the late, cicatricial stage. In scleroderma 
the pathological condition is an hypertrophy; in morphoea it 
is an atrophy. 

Treatment. — Unfortunately, but little can be done to re- 
lieve the condition. Various kinds of treatment have from 
time to time been instituted and carried out, with but un- 
satisfactory result. Constitutional remedies, such as iron, 
arsenic, and cod-liver oil, together with the employment of 
baths and stimulating frictions, in the form of liniments 
and ointments, offer the most hope of benefit. Galvaniza- 
tion, as recommended by Fieber* and Piffard,f may be em- 
ployed with the expectation of success. 

Prognosis. — The course and termination of the disease will 
be found to differ in cases. Occasionally the condition un- 



* Wiener Med. Wochenschrift, Nov. 26, 1870. 
f Loc. cit. 



SCLEREMA NEONATORUM. 365 

dergoes involution to recovery, while in other instances the 
symptoms remain persistently throughout life. The prog- 
nosis, upon the whole, is very unfavorable. Contraction and 
immobility of the parts may occur, attended by more or less 
deformity and suffering. 

SCLEREMA NEONATORUM. 

Syn. Scleroderma Neonatorum ; Induratio Telas Cellulosse Neonatorum ; 
Algor Progressivus ; Sclerema of the Newborn ; Germ., Das Sclerem der 
Nengeborenen ; Zellgewebsverh'artung der Neugeborenen ; Die Greisen- 
haftigkeit der Kinder; F?\, Algidite Progressive; Decrepitude Infantile. 

Sclerema neonatorum is a disease of infancy, appearing at 
birth or later, consisting of a diffused hardness and stiff- 
ness of the cutaneous and subcutaneous tissues, accompanied 
by coldness, oedema, swelling, discoloration, lividity, and 
general circulatory disturbance. 

Symptoms. — The disease may be congenital or may appear 
during early infancy. It usually begins in the lower ex- 
tremities, and extends upwards, involving the trunk, arms, 
and face. The skin frequently assumes a glossy, reddish, 
or purplish hue; in other cases it is yellowish, or even 
brownish. A mottled aspect, more or less marked, may be 
present. The integument appears stretched and tense. To 
the touch it offers a remarkable and striking induration; it 
is firm, hard, rigid, and incapable of being taken up between 
the fingers. The amount of hardness varies in places ; it is 
generally most marked about the legs. The surface is found 
to be cold, especially about the extremities. Upon pressure 
more or less oedema will be found, together with an in ni- 
trated, thickened condition of the tissues. On account of 
the rigidity of the parts, motion is interfered with ; this is 
usually seen very strikingly about the face, where the fea- 
tures remain fixed and give a staring, death-like expression 
to the child. When the disease is generalized, as in a case 
which recently came under my observation, the skin pos- 
sesses a strong resemblance to that of a half-frozen corpse, 
as regards both its appearance and feel. The child is un- 
able to move, takes but little nourishment, respires feebly, 
and usually sinks and dies in a few days. Very rarely, 
spontaneous recovery takes place. The disease is often 



3f)G HYPERTROPHIES. 

found associated with pneumonia and other troubles of the 
respiratory system. 

Etiology. — The causes are unusually obscure. It has been 
observed to occur most frequently in premature children. 
The capillary circulation is manifestly at fault; but whether 
this is the primary trouble, or is secondary, and dependent 
upon the structural change in the tissues, is as yet unde- 
termined. 

Pathology. — After death the skin is observed to undergo 
but little change; the coloring of the skin usually becomes 
more intense. The induration remains. Upon incision a 
very large quantity of yellowish, serous fluid is poured 
forth, after which the structures become softer and resemble 
ordinary (Edematous tissue. The subcutaneous tissue is 
seen to contain a stiff, firm, stearine-like deposit. Micro- 
scopic examinations have been made by Virchow,* Forster,f 
L6schner,{ Jenks,§ and others; with somewhat unsatisfac- 
tory results. Considerable cedematous infiltration is seen 
to exist throughout the tissues. The connective tissue of 
the corium is greatly increased, according to Loschner and 
Jenks; other observers, however, have not been able to 
determine this point. The stearine-like deposit is noted to 
occupy a large tract in the subcutaneous layers. 

Diagnosis. — The features of the disease are so well marked 
as to cause no difficulty in its recognition. The induration, 
oedema, and peculiar color of the skin, the coldness of the 
surface, the impaired circulation aud respiration, all point 
unmistakably to this disease. It differs from the sclero- 
derma of adults in the nature of the cutaneous deposit, as 
well as in its history and course. 

Treatment. — This should be directed against the general 
condition. Cutaneous stimulation, gentle frictions, warmth, 
and other like measures are to be resorted to and persevered 
in. The prognosis is very unfavorable. 



* Die Krankhaften Geschwiilste, I. Band, p. 302. 

f Path. Anatomie, II. Band, p. 1070, zweite Auflage. Leipzig, 1863. 

X Prager Yierteljahrschrift, 1868. 

|| Amer. Jour, of Obstet., May, 1871, p. 129. 



ELEPHANTIASIS ARABUM. 367 



ELEPHANTIASIS ARABUM. 



ISyn. Pachydermia; Boucnemia Tropica ; Elephant Leg; Barbadoes Leg ; 
pargosis. 

Elephantiasis Arabum is a chronic, hypertrophic disease 
OF the skin and subcutaneous connective tissue, charac- 
terized BY ENLARGEMENT AND DEFORMITY OF THE PART AFFECTED, 
ACCOMPANIED BY DISCOLORATION, PIGMENTATION, SWELLING, (EDEMA, 
THICKENING, INDURATION, AND PAPILLARY GROWTH. 

Symptoms. — The affection usually begins by an inflamma- 
tion of an erysipelatous nature, attended by general febrile 
symptoms, pain, heat, swelling, and oedema, followed by 
slight permanent enlargement of the part. During these in- 
flammatory attacks the lymphatics of the region and beyond 
it may be observed to be inflamed and distended, appearing 
as reddish or purplish stripes in and beneath the skin. The 
glands also become swollen and painful; this is particularly 
noticeable in the glands of the groin when a leg is invaded. 
Attacks of this description recur from time to time, the limb 
or region involved being slightly increased in size upon each 
occasion. After a year or longer, during which period a 
number of attacks will have taken place, the part will be 
seen to have attained considerable size; to be chronically 
swollen and cedematous and to be quite hard; and not only 
the leg but the skin itself to be generally hypertrophied, as 
shown by induration, enlarged and prominent papillse, fis- 
sures, and pigmentation. The process rarely ceases until 
the part has enlarged enormously, and is attended by serious 
deformity. 

The disease appears somewhat differently as one part or 
another of the body is affected. The common seat of the 
disease is the lower extremities, especially the legs. One 
limb only, however, is ordinarily attacked, the disease seldom 
showing itself symmetrically. The genitalia are the regions 
next attacked in point of frequency; the penis, scrotum, 
labia, and clitoris are all liable to be invaded. Other regions 
are much more rarely assailed, although cases are recorded 
in which the face, arms, and breasts have been involved. 

The leg being the usual seat of the trouble, a brief de- 



308 HYPERTROPHIES. 

scription of the appearances as ordinarily seen here will be 
given. After the affection has existed for some time, and 
as observed in a quiescent state between the inflammatory 
attacks, the leg will appear greatly hypertrophied, the 
enlargement beginning usually just below the knee and 
extending down to the ankle; the foot is only occasionally 
involved. The limb is distorted and swollen, the tissues 
pitting upon pressure and exhibiting marked signs of gen- 
eral thickening and induration. The skin is hypertrophied 
in all its parts. It may be either smooth or rough; when 
smooth, eczema is not infrequently present, and is the source 
of additional trouble. Papillary hypertrophy, in the form 
of wart-like prominences, varying in size, is apt to develop 
over the whole limb ; it is, however, more commonly present 
over the region of the foot and the toes. The growths 
may be either acuminated or flat in form, as in the case of 
the ordinary wart, and are traversed by the natural lines 
and furrows of the skin. Fissures, produced by the great 
distention and subsequent bursting of the integument, are 
also met with, while the normal folds of the surface are all 
exaggerated. Maceration of the epidermis, together with 
accumulations of extraneous matter, occurs about these folds, 
and gives rise to offensive masses of decomposition. Scales 
and crusts are apt to be present upon the limb, the latter 
being formed by the discharge, together with the blood 
and sebaceous matter, which continually oozes forth from 
between the wart-like formations. Ulcers are at times de- 
veloped from varicose veins, which frequently exist. More 
or less pigmentation, giving the whole limb a reddish, 
brownish aspect, also takes place. 

The amount of pain attending the disease varies consider- 
ably ; at times it is severe, especially during the inflammatory 
attacks, while in other cases but little inconvenience and 
discomfort are experienced. The weight of an aiFected part, 
as a limb or the scrotum, is always appreciable, and may be 
so great as to incapacitate the individual from walking or 
moving about. Where there is a tendency to eczema, itch- 
ing is an annoying symptom. 

The course of the affection is emphatically chronic. 



ELEPHANTIASIS ARABUM. 369 

Etiology. — Elephantiasis Arabum is found in all parts of the 
world ; it is, however, of more frequent occurrence in some 
countries than in others. It is especially common in trop- 
ical climates; Barbadoes, and the other islands of the West 
Indies, South America, China, Japan, Egypt, and Africa may 
be mentioned as affording many, as well as striking, examples 
of the affection. Isolated cases are encountered throughout 
both Europe and our own country. The largest number of 
cases are found to occur in low, malarial districts, upon 
islands, and along the sea-coast. 

Climate, it would appear from this statement, must be 
held accountable for a certain amount of influence in its 
development. It is, however, highly probable that the want 
of proper "hygienic measures, depraved habits, and bad food 
play a more prominent part in the production of the disease 
than climate, for the vitiated condition of the inhabitants of 
the tropical countries is well known. It has been noted 
universally that the affection is one confined in a great 
measure to the poor and improperly cared-for ; the well-to- 
do are seldom attacked. It is met with in both sexes, but 
is said to be more common in males. It rarely appears before 
puberty. The disease is neither hereditary nor contagious. 

Pathology. — The anatomy of the disease has been carefully 
studied by Virchow,* Kaposi, f and others. The tissues, 
when cut into with a knife, are found to be firm, and show 
a whitish or yellowish surface. The mass appears to be made 
up of both fibrous and fatty elements. When pressed upon, 
the sides of the cut tissue give forth a clear, pale-yellow 
fluid. As the centre of the growth is approached from the 
exterior, signs of fatty degeneration are encountered. 

Under the microscope, the great bulk of the growth is 
seen to be made up of hypertrophic connective tissue, having 
its seat, for the most part, in the subcutaneous connective 
tissue ; the corium is observed to be likewise hypertrophied, 
although proportionately to a much less extent. The mass 
is composed of bundles of stout fibres, running both parallel 



* Die Krankhaften Geschwiilste, I. Band, p. 308. 
•f Loc. cit., vol. iii. p. 140. 
24 



370 HYPERTROPHIES. 

and in various directions, as a network, together with smaller 
fibres and cells with nuclei. 

The corium and epidermis vary in thickness and structure 
according as the surface of the growth is smooth or covered 
with papillary elevations. These latter are oftentimes very 
greatly developed, forming condyloma-like growths, and are 
composed of elongated papillae, either with or without epi- 
dermic covering, according to their situation. The blood- 
vessels of the diseased tissue are found to be very materially 
enlarged. The lymphatics are, in like manner, seen to be 
increased in calibre, and in many instances to be greatly 
dilated. When the affection has continued for some time, 
various changes are noted to take place in the deeper parts 
of the structure, among which may be mentioned fatty de- 
generation and atrophy of the muscles, and thickening of 
the bones accompanied by exostoses. 

Diagnosis. — After the enlargement has begun to take place, 
no difficulty can exist as to the diagnosis. The erysipelatous 
inflammation, together with the part attacked, also points 
to the disease ; repeated attacks of erysipelas about a limb 
should always be regarded as indicative of a probable in- 
crease in the amount of connective tissue. 

It need scarcely be mentioned that no connection exists 
between the disease under consideration and elephantiasis 
Graecorum, or leprosy; the affixes Arabum and Grascorum 
distinguish the two affections. 

Treatment. — During an inflammatory attack the part should 
be treated by absolute rest — the horizontal position — and cold 
applications in the form of cold water cloths. After the pain 
and heat have subsided, the limb should be rubbed with mer- 
curial ointment, as suggested by Hebra, and encased in a 
well and closely applied bandage. The inunction should be 
repeated several times in the course of the twenty-four hours, 
with a view to the reabsorption of the exudation which has 
taken place. The bandage requires to be employed with 
skill, and to be adapted accurately and firmly to the limb, 
for it is all-important that it should exert the proper amount 
of pressure. Great diminution in the size of the limb will 
probably take place within the first few days of treatment, 



DERMATOLYSIS. 371 

during which period it will be found necessary to reapply 
the bandages several times in the course of the twenty-four 
hours. This method of treatment, together with rest, should 
be persevered in as long as any benefit seems to follow its 
employment. The constitutional symptoms accompanying 
the local disturbance are to be treated as the case may seem 
to require. When the disease has existed for some time and 
great deformity is present, ligation of the main artery sup- 
plying the limb, or even amputation of the limb, may be 
practised. In cases in which the genitalia are involved, the 
knife offers the best means of relief. 

Prognosis. — If the affection is placed under proper treat- 
ment early in its course, much may be done to arrest the 
process, or at least to prevent its rapid increase. When, 
however, the growth has become fully developed and new 
tissues have become organized, but little permanent relief 
can be looked for. Striking deformity attends the disease, 
the part involved usually attaining great size and weight, 
while not infrequently, in the course of years, a limb will 
assume truly huge proportions, resembling in contour as well 
as in bulk the foot of an elephant. The penis, scrotum, and 
labia likewise enlarge at times enormously, forming solid 
tumors, often weighing many pounds.* In these cases loco- 
motion is seriously interfered with, if not altogether prevented. 
Individuals affected with elephantiasis Arabum seldom perish 
from the effects of the disease ; in rare cases, however, a fatal 
result may follow an inflammatory attack. 

DERMATOLYSIS. 

Syn. Cutis Pendula ; Pachydermatocele ; Hypertrophy of the Skin 5 Pen- 
dulous Growth. 

DERMATOLYSIS CONSISTS OF A MORE OR LESS CIRCUMSCRIBED 
HYPERTROPHY OF THE CUTANEOUS STRUCTURES, CHARACTERIZED BY 
SOFTNESS AND LOOSENESS OF THE SKIN, AND A TENDENCY TO HANG 
IN FOLDS. 

Symptoms. — It may exist as a slight affection, or to such an 

* A huge scrotal growth of this character recently came under observation 
at the Hospital of the University of Pennsylvania ; it was successfully re- 
moved by Dr. John Neill. Amer. Jour, of the Med. Sci., July, 1875. 



372 HYPERTROPHIES. 

extent as to cause serious inconvenience. The skin and all 
its component parts, including hairs, follicles, glands and 
ducts, as well as the deeper structures, are hypertrophied. 
The tissues are greatly thickened, exceedingly bulky, and 
incline to hang in folds or pouches; very commonly the 
layers lap over one another, like the folds of a loose garment. 
To the touch the skin is soft and pliable, and is remarkable 
for its laxity, reminding one of adipose tissue. Its surface is 
rugous, owing to the hypertrophy of the follicles and natural 
folds and lines of the part; it has the appearance of being 
viewed through a powerful magnifying glass, all the structures 
being highly exaggerated. There is more or less pigmenta- 
tion present; the skin is at times brownish in color. 

The affection may be confined to a certain region, as the 
face; or, it may show itself in several distinct localities, as 
upon the face and arm. It has been observed to occur about 
the head, face, neck, arms, abdomen, genitalia, thighs, and 
legs; it may, however, make its appearance upon any part of 
the body. One or a number of the growths may be present 
about the same region ; where several exist they are apt to 
develop in close proximity, side by side, and to crowd one 
another into layers or folds ; occasionally purse-like, depend- 
ent pouches are formed. The course of the disease is slow. 
It occasions, as a rule, no trouble beyond the inconvenience 
of so bulky and heavy a growth. 

The tissues may develop to an enormous size, as in the 
case of 2s"elaton, reported by Keen,* where the hypertrophy 
sprang from the back of the neck and shoulders, and fell 
in the form of a huge cloak over the whole baek, reaching 
down to the buttocks ; its weight was twenty-five pounds. 
The late Prof. Valentine Mott, of New York, reported five 
cases of this disease, portraits of two of which accompany his 
communication.f Stokes, of Dublin, has recently reported a 
case, with a drawing, upon which he performed a successful 
operation. J Mr. "Weeden Cooke's case, which I had the good 



* Photographic Keview of Med. and Surg., vol. ii. p. 45. 
f Med.-Chir. Soc. Trans., vol. sxxvii. p. 155. 
j Dublin Jour, of Med. Sci., Jan., 1876. 



DERMATOLYSIS. 373 

fortune to see when in London, in 1869, may also be re- 
ferred to. The subject was a girl of seventeen, who was 
affected with an enormous hypertrophy of the cutaneous 
tissues about the left hip and thigh, extending down as far 
as the knee, and there abruptly terminating. The integu- 
ment was greatly hypertrophied, and hung loosely and 
flabbily in folds, one overlapping the other, resembling in 
appearance the leg of a pair of loose Turkish trousers. 
These folds were four or five in number, and could be 
readily lifted up separately with the hand. The commence- 
ment of the growth dated back only three years, and latterly 
it had increased with great rapidity. It probably weighed 
fifteen pounds or more, and it interfered seriously with loco- 
motion. I have also in my possession a photograph kindly 
sent to me by Dr. Hodges, of Boston, illustrating the same 
affection ; the growth in this case extends from the left 
shoulder to the elbow, hanging over the forearm and almost 
reaching the wrist, looking very much like the open sleeve 
of a lady's dress. 

Etiology. — No cause can be assigned for the abnormal de- 
velopment; at times it is congenital, in other cases, as in 
that of Mr. Cooke, it does not make its appearance until 
puberty or later. 

Pathology. — The growth consists primarily of a simple 
hypertrophy of the skin, including all its structures, and of 
the subcutaneous connective tissue. 

Diagnosis. — No difficulty can arise in recognizing this dis- 
ease, the features of which are usually so well defined. It 
is not to be confounded with rnolluscum fibrosum, nor with 
elephantiasis Arabum. 

Treatment. — The knife offers the only means of removing 
the mass. The advisability of an operation must depend 
altogether upon the location and extent of the growth. 

HYPERTROPHY OF THE HAIR. 

Syn. Hypertrichosis ; Trichauxis 5 Polytrichia. 

Under this head are included all those cases in which the 
hairs are unusually developed, as regards their size and 



374 HYPERTROPHIES. 

number, either upon regions where the hair is ordinarily 
found, or in places where the growth is abnormal. 

The hair upon the scalp in both sexes not infrequently 
grows to an unusual length and in great quantity; it may 
be either of the average thickness, or finer or coarser than 
normal. The hair in other localities to which it is natural, as 
the eyebrows, axillae, pubis, and beard in men, may also take 
on augmented growth and attain uncommon development. 
Instead of the fine, downy hairs, or lanugo, present over 
the greater portion of the body, increased activity of hair 
growth may manifest itself, either universally, over the whole 
surface, or locally, in certain parts, as the face, which may 
continue until the body is extensively covered with long, well- 
formed, more or less stout hairs. This form of development 
also takes place in both sexes, and at all periods of life. 
It often gives rise to much disfigurement in the female. In 
these cases the hairs are apt to assume a more luxuriant 
growth in those localities in which the hair is naturally 
strongest. Examples of these so-called "hairy people" are 
from time to time met with, extraordinary cases of which 
have now and then been reported.* 

Stout, stiff, and sometimes long hairs are of common oc- 
currence in connection with moles, when the formation is 
termed a n^ivus pilosus; if it possess a rough, uneven, warty 
surface it is called a NiEVUS verrucosus. These growths are 
encountered upon various regions; existing upon the scalp, 
the hairs are usually noted to be greatly increased in cali- 
bre; at times so much so as to resemble the hair of the 
lower animals. 

Hairs occasionally show abnormality as regards the direc- 
tion in which they grow after making their exit from the 
follicle; the condition is termed trichiasis. It is seen upon 
the scalp and eyebrows, and upon the eyelashes, where, at 
times, the hairs exhibit a tendency to turn inwards towards 
the eyeball. 

The condition known as plica or plica polonica (common 



* See Wilson, loc. cit., p. 716; Hebra and Kaposi, vol. iii. p. 69; Rayer, 
Treatise on Diseases of the Skin, English translation, London, 1835, p. 1040. 



HYPERTROPHY OF THE HAIR. 375 

in Poland, and observed chiefly among the poorer classes), 
in which the hair, through long-continued neglect, unclean- 
liness, and at times the presence of lice and of eczema, be- 
comes closely matted together in the form of a mop, may 
be here referred to. It is not a disease, as was formerly 
supposed, but merely an entangled, felted, filthy state of 
the hair and scalp, brought about by inattention to comb- 
ing, cutting, and cleansing this portion of the person. It is 
remedied by the free use of oils, soap and water, and the 
comb and brush ; or by means of the scissors, cutting off 
the whole mass. It is rarely encountered in this country, 
at least to any extent. 

Etiology. — Nothing definite can be stated in regard to the 
causes of these abnormal developments. They may be con- 
genital, the usual case, or they may be acquired, the dispo- 
sition to increased growth first showing itself later in life. 
Excessive hairiness is more common in persons of dark than 
in those of light complexion. In women, when the con- 
dition is acquired, as at times observed about the face and 
arms, masculine peculiarities are very often present. It also 
occasionally manifests itself in women at the climacteric 
period; also in sterile women, and in those whose menstrual 
function is imperfect. Local stimulation or irritation of a 
part may be mentioned as one of the causes which has not 
infrequently been noted by observers. Cases have been re- 
corded in which lanugo developed itself into strong, stiff 
hairs over the site of a former blister. 

Treatment. — The removal of these augmented growths of 
hair is usually confined to small areas, as, for example, hairy 
nsevi, the upper lip, and face generally of women. Where 
the hairs are few in number, they may be extracted with the 
epilating forceps. In the case of nsevi, excision or cauteriza- 
tion of the whole formation is to be recommended as offering 
the most effectual and permanent relief. Shaving, with the 
use afterwards of starch or French chalk dusting powder, is 
a method very commonly employed; in many cases it is the 
simplest and best means of removing the disfigurement. 

Depilatories, remedies of a caustic nature which act de- 
structively upon the hairs, are often of service in destroying 



376 HYPERTROPHIES. 

patches of hair. They consist usually of several substances 
mixed in varying proportions, the active ingredients being 
either sulphide of arsenic, sulphide of sodium, sulphide of 
barium, sulphide of calcium, or quicklime. The so-called 
"depilatory powders" are formed of one or another of these 
preparations, reduced to impalpable powder and mixed with 
starch. They are made into a paste, with a small quantity 
of water, and laid on the hairy part to be destroyed, as a thin 
coating, for ten or fifteen minutes. As soon as heat of skin 
is experienced, the paste should be scraped off and the sur- 
face washed with water and immediately anointed with some 
bland ointment ; afterwards a starch powder may be applied 
to conceal the signs of irritation upon the skin. 

The sulphide of barium is one of our best remedies for this 
purpose. I have used and can recommend the following : 

R Barii Sulphidi, ^ii ; 

Pulv. Oxidi Zinci, 

Pulv. Amyli, aa ziii. 
M. 

All of these preparations should be employed with caution, 
and only under the direction of a physician ; on account of 
their caustic properties, they are not infrequently the source 
of mischief. They require to be repeated in their use every 
few days, or as the case may demand. 

HYPERTROPHY OF THE NAIL. 

The nail structure may augment itself in various direc- 
tions; as, in length, in width, or in thickness. The term 
hypertrophy of the nail is applied to any increase in size, 
from whatsoever cause. 

Supernumerary nails have occasionally been observed; so 
also nails upon regions of the body where this structure 
does not usually exist, as upon the extremities of amputated 
fingers, where no rudiment of the original matrix can have 
existed.* 

Hypertrophy may take place as an idiopathic affection, 

* Wilson, loc. cit., p. 709. 



HYPERTROPHY OF THE NAIL. 377 

occurring independently of disease in other parts of the 
body ; or it may appear in connection with certain general 
or constitutional disorders, as ichthyosis and syphilis. The 
process may manifest itself as a simple increase in the nor- 
mal growth of the nail, termed onychauxis; or, as is more 
usually the case, it may be attended with changes of color, 
consistence, and shape. When the nail inclines to grow 
forwards and to the side, in a twisted, bent, or curved man- 
ner, like the horn of a ram, the condition is called onycho- 
gryphosis. The nails here are usually much thickened, and 
are hard and horny ; they are yellowish or brownish in color, 
and are curved into various shapes. One, several, or all of 
the nails may be so affected. It takes place more frequently 
upon the toes than upon the fingers, and is ordinarily seen 
only in old people. 

The skin immediately around the posterior outer surface 
of the nail, inclines at times to grow over the back of the 
nail ; when this occurs it is designated pterygium of the 
nail. 

Hypertrophy of the nails is apt to take place as the result 
of certain diseases of the skin, as psoriasis, ichthyosis, 
leprosy, syphilis, etc. The appearances presented in these 
affections vary, although usually marked by more or less 
softening and exfoliation. Hypertrophy of the papillae of 
the matrix occasionally occurs, causing the nail to become 
thickened upon its exposed surface. Increase in the color- 
ing matter of the nail, producing yellowish, brownish, or 
blackish discoloration, is also to be mentioned as one of 
the abnormal states now and then encountered ; it may exist 
as an idiopathic affection, or in connection with other dis- 
eases. 

The nail at times takes on an abnormal direction of growth, 
extending itself laterally into the soft parts. When this oc- 
curs, inflammation of the skin is apt to be produced, giving 
rise to paronychia. 

The matrix of the nail not infrequently becomes the seat 
of inflammation and of new formations, followed by changes 
of structure of the nail-substance ; the condition is termed 
onychia. It may result from external injuries, pressure, etc., 



378 HYPERTROPHIES. 

or from certain diseases. Eczema, psoriasis, leprosy, and 
syphilis, are all known to attack the matrix. 

Syphilitic onychia is due to the cellular deposit of syphilis 
taking place about the matrix of the nail, which undergoes 
the same pathological changes as this formation is subject to 
in other regions of the body, modified by the peculiar ana- 
tomical structure of the part. One or more nails may be 
affected. The process frequently extends itself to the cuta- 
neous tissues around the nail, producing redness, swelling, 
ulceration, and a copious discharge of very offensive, puri- 
form fluid. It is apt to be accompanied by hypertrophy and 
other structural change of the nail-substance. The nail not 
infrequently becomes detached from the matrix. 

The vegetable parasites at times make their habitat be- 
neath the nail, as well as in its very substance, which they 
penetrate in all directions, producing increase in size, and 
subsequently general disintegration of the tissue ; the con- 
dition is termed onycho-mycosis. Several or all of the nails 
may be attacked. 

Treatment. — This will vary with the cause, which must in 
each case be sought for. Both local and constitutional reme- 
dies are employed, either alone or conjointly, according to 
the nature of the affection. Idiopathic hypertrophy of the 
nail may be removed by the knife or scissors, after the 
growth has been softened or macerated by hot water baths 
or poultices. It is at times advisable, at the first operation, 
to remove a portion only of the hypertrophy, on account of 
the liability to split, which nails frequently evince. 

In-growing nails should receive careful attention in the 
avoidance of all pressure, frequent cutting, and protection 
of the soft parts by means of lint placed between the nail 
and skin-fold. Alterations in the nail through constitutional 
diseases, as, for example, syphilis, must receive general treat- 
ment suitable to the case. Nails invaded by fungi are to be 
treated as in the case of the parasite when upon the skin, 
— by parasiticides, together with internal remedies, if they 
seem to be indicated. 



CLASS VI. 
ATROPHIES. 

In this class may be grouped all those affections of the 
skin and its component parts which are characterized by a 
diminution or degeneration of the elements which go to 
make up the normal structure. 

The changes which take place may be due to simple 
atrophy, as of the pigment in gray hair; to a combined pro- 
cess, including both atrophy and hypertrophy, the atrophy, 
however, predominating, as in vitiligo; or, to so-called de- 
generative atrophy, as in morphcea. 

The absence of the proper amount of coloring matter in 
the skin gives rise to more or less disfigurement, varying in 
degree according to the extent to which it is wanting. It 
may exist either as a congenital or as an acquired condition. 
When congenital it is termed albinism. 

Acquired {i.e., making its appearance during the life of 
the individual) absence of pigment in the skin may be idio- 
pathic, as in vitiligo; or it may occur in the course of other 
diseases, as, for example, in patches, following excoriations, 
ulcers, etc. 

The pigment of the hair is very frequently absent in part 
or wholly, giving rise to varying degrees of canities. The 
skin itself occasionally suffers from premature atrophy, either 
in a diffused or in a circumscribed form, usually the latter, 
as in the stria? et macula? atrophica?, and in morphcea. The 
hair of the scalp and the scalp itself are very commonly the 
seat of atrophy, as in alopecia from various causes, and in 
alopecia areata. The nail is also now and then attacked. 



380 ATROPHIES. 






ALBINISM. 

Syn. Albinismus; Congenital Achroma; Congenital Leucopathia; Con- 
genital Leukoderma ; Congenital Leucasmus. 

The condition which has been termed albinism consists of 
a congenital absence of the normal pigment. It may exist 
uniformly over the whole of the surface, in which case it is 
said to be universal ; or, in the form of circumscribed patches, 
when it is designated as being partial. 

As a universal anomaly it is met with in people of various 
races, who have received the name of Albinos. These in- 
dividuals are characterized by the more or less complete 
absence of coloring matter in the skin and hair, and even in 
the iris and choroid coat of the eye. The skin is of a milky- 
w T hite or pinkish color, varying as to shade. The hair of the 
head, as well as of the hairy portions of the body, is also 
white or yellowish-white; at times it is as white as snow, 
and has a silvery appearance. It is, moreover, fine, thin, 
and usually soft and silky. The lanugo covering the body 
is exceedingly fine, like that of an infant. 

The eyes are highly sensitive to light ; so much so that 
they are scarcely able to tolerate daylight. The pupils dilate 
and contract constantly, the eyeballs incline to oscillate, and 
there is almost continuous involuntary winking of the eye- 
lids. In color the iris is pale-bluish or pinkish, while the 
pupil presents a pinkish or bright red appearance, owing to 
absence of pigment in the choroid. Albinos, as a rule, are 
of short stature, and are usually deficient in strength and in 
mental capacity. It is said that they almost always have a 
disposition to diseases of the chest. 

Partial albinism is seen in the negro. Kaposi is of the opin- 
ion that it also occurs in the white race. It consists of one 
or more variously sized and shaped milky-white or pinkish- 
w T hite patches, which may occur upon any region. The hairs 
or lanugo which may exist upon a patch are blanched, as in 
the case of universal albinism. The eyes are not deprived 
of pigment. Negroes thus affected are designated "pied" 
or u piebald" negroes. 

Albinism, although of rare occurrence, is met with in all 



VITILIGO. 381 

races, and among those of cold as well as those of hot 
climates. It occurs in Africa, the various countries of Eu- 
rope, and in our own country, especially among the negroes 
of the South. The causes are unknown. The condition is 
frequently, although by no means always, inherited. One 
child only out of a family may be so affected. It is incurable.* 

VITILIGO. 

Syn. Acquired Leucoderma ; Acquired Leucopathia; Acquired Leucasnius; 
Acquired Achroma ; Acquired Piebald Skin. 

Vitiligo is an acquired disease, consisting of one or more 
sharply-defined, round, oval, or irregularly-shaped, vari- 
ously sized and distributed, smooth, whitish spots, whose 
borders show an increase in the normal amount of pigmen- 
TATION. 

Symptoms. — The disease commences by the appearance of 
one or more variously-sized spots, which are observed to 
increase slowly or rapidly in size ; new ones are apt to show 
themselves from time to time. The number of spots varies 
from several to a dozen or more; usually, however, they are 
not numerous. Their outlines are well defined and termi- 
nate abruptly against skin which is observed to be darker 
than normal, commonly of a yellowish or brownish tint. 
They have a smooth surface, and are always on a level 
with the surrounding skin, being neither raised nor de- 
pressed. In shape they are for the most part roundish ; they 
are also frequently oval, and at times, especially about the 
face, their outline is quite angular and irregular. In size 
they vary, according to their age and the rapidity with which 
they enlarge ; they may be of all sizes from a small coin to 
the palm of the hand and larger. Ultimately, as they grow 
towards one another, they coalesce, forming larger patches, 
which may cover the greater part of a limb or the trunk. 
They have a milky-white color, varying somewhat in shade, 
which is at once seen to be due to the absence of the normal 
pigment of the skin. Hairs existing in their area may or may 

* For the notes of several interesting cases, see Kayer's Treatise on the 
Diseases of the Skin, English translation, London, 1835, p. 932. 



382 ATROPHIES. 

not be whitened. The sebaceous and sudoriparous secretions 
remain normal. Sensibility likewise is preserved; there is 
neither itching, pain, nor anaesthesia. The skin feels normal 
to the touch. The increased coloration surrounding the spots 
is a constant feature ; at times it is present only to a slight 
extent, in other cases it is very marked. It is seen to be a 
diffused pigmentation, becoming more intense in tone as it 
approaches and touches the spot; beyond, it fades gradually 
away into the healthy skin. 

The disease may appear upon any part of the body, from 
the feet to the top of the head, upon both hairy and non- 
hairy regions. Very commonly it occurs upon the backs of 
the hands and feet, also upon the trunk. 

The course of the affection is exceedingly chronic; it 
usually lasts throughout life, the spots increasing slowly 
in size as well as in numbers until the greater portion of 
the skin may be involved. The disfigurement is striking, 
and proves a constant source of annoyance to the patient, 
especially if the lesions chance to make their appearance 
about the face. 

Etiology. — The affection is quite rare. It is encountered in 
both sexes, in light- and in dark-haired people, in various 
races, and usually first shows itself in adult life. The general 
health is ordinarily noted to be good ; at times, however, it 
is at fault. The nervous system may be implicated. As a 
rule, no satisfactory cause can be offered for its development. 

Pathology. — The process consists in both an atrophy and a 
hypertrophy of the normal pigment of the skin, which appear 
to take place simultaneously. One part of the skin seems to 
suffer at the expense of the other. Microscopic examination, 
according to Simon,* shows a total absence of the coloring 
matter in the whitish spots, while the yellowish or brownish 
discoloration which surrounds each spot is found to contain 
an excess of pigment. 

Diagnosis. — The disease is not to be confounded with chlo- 
asma, which it resembles. In vitiligo the spots are whitish, 
clearly defined, and are surrounded by deep pigmeutation; 

* Loc. cit., p. 63. 



VITILIGO. 383 

in chloasma the spot itself is yellow or brownish, and is 
unaccompanied by any whiteness whatsoever. 

Vitiligo may also be mistaken for tinea versicolor; but 
here, as in chloasma, the patches themselves are yellowish, 
the skin between them being normal in color. The skin, 
moreover, in vitiligo, is perfectly smooth and without scale ; 
in tinea versicolor it is always furfuraceous. The microscope 
will further aid in the diagnosis. 

Vitiligo is also to be distinguished from morphcea. These 
two affections, however, differ in so many particulars as 
scarcely to permit of confusion in diagnosis; the spots of 
morphcea may be known by the marked alteration which 
takes place in the structure of the corium. 

Treatment. — Where the general health is impaired, or where 
there is functional derangement, strict attention should be 
devoted to improving the condition. A full tonic treatment 
should be persisted in for some time; without doubt this 
plan offers the best chance for the arrest of the abnormal 
process. 

In regard to local treatment, the greatest amount of success 
will attend the removal of the yellow and brownish discol- 
orations immediately around the whitish spots, as recom- 
mended by Hebra and others. The hypertrophy of the 
pigment, rather than the atrophy, is to be treated; this is 
done exactly in the manner described in speaking of the 
chloasmata. Upon the whole, the treatment of vitiligo is 
extremely unsatisfactory. 

Prognosis. — It will be found, as a rule, that the spots incline 
to increase in size very slowly, extending over a period of 
years, until a considerable portion of the surface is occu- 
pied; they are seldom arrested in their progress. At times, 
however, they cease growing, and remain at a stand-still for 
the rest of life. In rare cases the skin has been known to 
become normal again. The disease is attended by no un- 
pleasant symptoms beyond the disfigurement. 



384 ATROPHIES. 

CANITIES. 

Syn. Grayness of the Hair; Whiteness of the Hair; Blanching of the 
Hair; Atrophy of the Hair Pigment; Trichonosis Cana; Trichonosis Dis- 
color. 

This may occur either prematurely, early in life, or, as is 
much more commonly the case, later, as the result of old 
age, when it is termed senile canities. 

Premature grayness of the hair may show itself either 
universally, involving the whole of the hairy system, or in 
places, forming tufts or locks of gray or white hair. The 
color may be of any shade from black or brown to white ; 
usually it is gray. The hairs may be discolored through- 
out their entire length or only at certain points; the shade 
may also vary in different places. The affection may occur 
at any age, but is rarely seen before adult life. After the 
process has taken place the hairs either remain without their 
normal supply of coloring matter throughout the rest of life, 
or, after a longer or shorter period, regain it; the course is 
variable. 

The length of time which the hairs require for the com- 
plete change of color is found to vary exceedingly, being at 
times very rapid and in other cases slow. The question as 
to whether hairs can be deprived of their color suddenly, i.e., 
within twenty-four hours, is differently answered by observers. 
Hebra and Kaposi* are of opinion, based upon physiologico- 
anatomical grounds, that the change can take place only 
gradually, and consequently that the several well-known re- 
ported cases in which the graying is said to have occurred 
" in the course of the night" cannot be received as absolutely 
true. In opposition to this view, Wilsonf and LandoisJ 
may be cited as crediting the occurrence of this sudden 
change, the last-named observer endeavoring to explain the 
phenomenon by the presence of air bubbles which he believes 
take sudden possession of the interior of the hair. 

* Loc. cit., vol. iii. p. 192. f Loc. cit., p. 732. 

J See an interesting case of "sudden graying of the hair" by this writer in 
Yirchow's Archiv, April, 1866. Cases are also reported by Dr. D. H. Tuke, 
il Influence of the Mind upon the Body," Arner. ed., p. 276, Phila., 1873. 



ATROPHIA CUTIS. 385 

Internal remedies do not appear to exert any influence in 
restoring the pigment. Dyeing of the hair may be resorted to 
to disguise the condition. 

ATROPHIA CUTIS. 

Syn. Atrophia Cutis Propria 5 Atrophy of the Skin. 

Atrophy of the skin is characterized either by a diminu- 
tion in its bulk, or by a degeneration of its elements. 

Simple atrophy is marked by a general decrease in the 
number of the normal constituents of the tissue; the skin is 
thin, is more or less wasted, and presents a dried, shrivelled 
appearance. 

Degenerative atrophy exhibits structural alteration, with 
or without actual loss of substance. The tissue so affected 
is usually observed to be somewhat hardened, to be yellow- 
ish or whitish in color, and to have a waxy, fatty, bacony 
look. 

The atrophic process may be general in character, as in 
senile atrophy, and in certain rare forms of disease; or it 
may be partial or limited in its invasion, as in atrophic lines 
and spots, and in morphoea. 

Atrophy of the skin may occur as a substantive disease 
(idiopathic atrophy) ; or, as a symptom in the course of some 
other disorder (symptomatic atrophy). The former is seen 
in the atrophic lines and spots, in morphoea, and in senile 
atrophy ; while the latter takes place in connection with or 
following certain constitutional and local disorders, as, for 
example, seborrhcea, lupus, syphilis, and tinea favosa. 

The singular and rare affection termed unilateral atrophy 
of the face,* in which an arrest of development of all the 
structures of one side of the face occurs, may be here men- 
tioned. The cutaneous structures, especially the corium, 
are all seriously involved, the skin appearing as a shrunken, 
hardened, yellowish, lardaceous tissue. 

General idiopathic atrophy of the skin is a very rare 

* For further information concerning this disease, see " Essai sur l'Aplasie 
Lamineuse Progressive," by Lande, Paris, 1870; also Eulenberg's "Lehrbuch 
der functionellen Nervenkrankheiten," Berlin, 1871. 

25 



386 ATROPHIES. 

condition ; it has, however, been observed by Wilson,* and 
by Hebra and Kaposi. f 

STRIJE ET MACULJE ATROPHICJE. 

Syn. Atrophic Lines and Spots. 

This form of atrophy may be either idiopathic or symp- 
tomatic. 

Idiopathic. — The atrophy here occurs without known 
cause, often making its appearance so indolently and gradu- 
ally that the attention of the patient is not directed to the 
lesion until it has existed perhaps for some time. The pro- 
cess may assume the form either of lines or streaks (atrophia 
cutis linearis, linear atrophy), or of spots ; the former are 
much the commoner. The lines are usually one or two lines 
in width, and vary in length from one to several inches. The 
spots are roundish, and from a pin-head to a pea or larger in 
size. They possess a smooth, glistening, scar-like appear- 
ance, and have a whitish, bluish-gray, mother-of-pearl color. 
The lines are slightly depressed or grooved (striae), perceptible 
to the touch, and have an irregular, broken, curved or modu- 
latory course. A number of them are generally found upon 
the same region ; in which case they usually run parallel to 
one another, and almost always in an oblique direction. 

They may occur upon any part of the body; they are, 
however, most frequently seen about the thighs, upon both 
extensor and flexor surfaces.^ They give rise to no incon- 
venience. The general health of the patient is usually good. 
They ordinarily run a slow course, lasting years. Their 
cause is obscure. They are found in both men and women; 
at all periods of life ; and may occur either alone, or in con- 
nection with other diseases. I have seen them in two cases 
associated with morphcea. 

Kaposi § examined an excised atrophic line, and found 
the epidermis, especially the mucous layer, very much atro- 

* Loc. cit, pp. 393, 394. f Loc. cit., vol. iii. p. 252. 

J See a recent article by Dr. R. W. Taylor, Archives of Dermatology, vol 
ii., No. 2, 1876. 

I Loc. cit., vol. iii. p. 262. 



MORPH(EA. 387 

phied; the papillae of the corium almost entirely obliter- 
ated; the connective and elastic tissue in very thin bundles; 
the bloodvessels few and slender; the fat cells absent; and 
the sebaceous glands wasted and degenerated. 

Symptomatic. — The atrophy here results from various 
causes, as from extreme distention of the cutaneous tissues 
in pregnancy, in large abdominal and other tumors, and in 
the mammse during lactation. The skin in these conditions 
becomes enormously stretched, and finally gives way in 
the form of lines, which subsequently atrophy (line,e albi- 
cantes). Wilson* states that linear atrophy may at times 
occur in the course of a nerve which has been disorganized. 

MORPHCEA. 

Syn. Keloid of Addison. f 

Symptoms. — The disease usually commences by the develop- 
ment of one or more small, roundish patches, which slowly 
increase until they assume the size of a coin or the palm of 
the hand. They are circumscribed, their periphery being 
marked by an abrupt line of demarcation. Immediately 
around the patch is observed a pinkish or violet border, 
about a line in width, more or less well defined, which is 
seen to be made up of minute bloodvessels. The patch is 
never elevated ; it is either on a level with the surrounding 
skin, or, if the disease be of long standing, somewhat de- 
pressed. To the touch it is usually firm ; in other cases 
it appears to be very little different from the feel of normal 
tissue. Its surface is smooth, and often possesses a polished, 
glazed look. The epidermis may be either unaltered or in a 
state of atrophy. The color is peculiar; it is at first pinkish, 
but becomes whitish or yellowish, and so remains through- 



* Loc. cit., p. 395. 

f I include under the term morphcea, two forms of disease heretofore con- 
sidered by writers under the names "keloid of Addison" and " morphcea," 
believing that they are but different manifestations of one and the same 
process. The so-called "morphcea of leprosy," although often resembling 
the disease under consideration, is but one of the many cutaneous symptoms 
of that disease, and is in no way connected with the affection about to be 
described. 



388 ATROPHIES. 

out its course. The patch possesses a waxy look ; it may 
also be likened to a section of a piece of bacon which has 
been cut out and laid in the skin, presenting the appear- 
ance of a lardaceous deposit. It is always dry, and after 
a time may take on a shrivelled, wasted appearance. One 
or two or more of these patches may exist; commonly but 
one or two are present. They are encountered about the 
region of the neck, upon the trunk, arms, and thighs. 

In place of the symptoms just described, the disease may 
show itself by lesions of a more distinctly atrophic nature, 
consisting of numerous aggregated or disseminated, small, 
pit-like depressions in the skin; bluish or reddish tortuous 
lines ; whitish atrophic streaks (true " striae atrophica^ 
cutis"); decided yellowish or brownish pigmentary deposit; 
together with one or more definite centres of disease, red- 
dish or purplish in color, followed by peculiar, yellowish, 
hard, horny, cicatriform lesions assuming the shape of round- 
ish, coin-sized patches, or elongated, band-like formations.* 
The whole process is exceedingly complex and variable. 
The arms, thighs, and legs are particularly liable to be 
attacked, although the body may also suffer. Sooner or later 
the deeper tissues may become affected, contraction taking 
place, with serious deformity. One, several, or all of these 
manifestations may be present, f Their course is extremely 
variable ; they may continue throughout a lifetime, in- 
creasing in severity from year to year, or they may undergo 
spontaneous involution, terminating in recovery. 

The subjective symptoms of morphoea are not noteworthy; 
at times there is slight itching about the patches. 

Etiology. — The disease is very rare. It has been noted to 
occur more frequently in females than in males, and has been 
observed in both children and adults. The causes are alto- 
gether unknown; it does not depend upon debility, many 



* For a full description of these appearances, see the reported cases of 
Addison, to he found in u A Collection of the Published "Writings of the late 
Thomas Addison." New Syd. Soc, London, 1869. 

f A case, occurring in a young lady, eighteen years of age, is at present 
under my observation, in which all of the mentioned symptoms exist. 



MORPH(EA. 389 

of the reported cases enjoying good general health. The 
affection has no connection whatsoever with leprosy. 

Pathology. — But little is known concerning the nature of 
the process. The more important changes which take place 
are manifestly of an atrophic nature. No microscopic exam- 
ination has as yet been made upon tissues thus affected. 

Diagnosis. — The relationship between the conditions desig- 
nated in literature by the names morphoea, keloid of Addison, 
scleroderma, and strife et maculae atrophica, are variously 
interpreted by observers. 

Morphcea differs from scleroderma in that its lesions 
are more or less circumscribed ; this is particularly the 
case in the macular form of the disease, where the patches 
exist as well-defined, circumscribed, yellowish, lardaceous, 
inlaid plates. It also differs from scleroderma in the absence 
of the peculiar sclerodermic hardness. In the later stages 
of morphoea, where distinct atrophy and cicatrization have 
occurred, the condition will scarcely be confounded with 
scleroderma. (See scleroderma, p. 364.) 

The atrophic striae of morphcea, as seen in one form of the 
affection, are with difficulty to be distinguished from the 
"lineae albicantes" so often seen upon the abdomen. Other 
symptoms of quite a different nature, as, for example, pig- 
mentation and cicatrization, will usually be present in mor- 
phcea, whereby these two conditions may be separated. 

The roundish, circumscribed patches of morphcea bear a 
strong resemblance to the anaesthetic spots of leprosy. In 
general appearance these two forms of disease possess many 
features in common ; but upon investigation they are found 
to differ in many very important particulars. The reddish 
or yellowish patches or macules of leprosy are well-known 
symptoms common to both the tubercular and the anaes- 
thetic variety of the disease. When fully developed they 
are always anaesthetic, and are usually accompanied by other 
symptoms of leprosy. Neither anaesthesia nor hyperesthesia 
occurs at any period in connection with the patches of 
morphoea. 

The whitish patches of morphoea bear some likeness to 
vitiligo ; but in vitiligo the disease is one affecting the pig- 



390 ATROPHIES. 

mentary layer only, the texture of the skin itself being in 
every respect normal, and hence could not be confounded 
with the structural change in the skin which takes place in 
morphcea. 

Treatment. — A general tonic treatment is called for, con- 
sisting of the liberal use of cod-liver oil, the preparations of 
iron, and arsenic. The last-named remedy should be given 
in full doses, and continued for a long period. Where arsenic 
is to be used for months it is of the greatest importance to 
begin with small doses, very gradually increasing the 
quantity until the patient takes as much as possible without 
disturbing the general health. More benefit probably is to 
be derived from the judicious use of arsenic in this affection 
than from any other remedy. The constant galvanic cur- 
rent may prove of service. 

Prognosis. — It is always an exceedingly chronic form of 
disease, undergoing very slow and gradual evolution ; it is 
apt to continue throughout life. At times it inclines to 
spontaneous recovery. Where extensive atrophy has already 
taken place, complete restoration cannot be looked for. 

SENILE ATROPHY. 

This form of atrophy, as its name implies, takes place as 
the result of old age. The alterations encountered are quite 
varied in their character, and affect not only the corium, 
but also its component parts and the subcutaneous tissues. 
The process may be either simple or degenerative; very 
commonly both processes occur together. 

In simple atrophy, the skin, especially the corium, is always 
thin; the surface, moreover, is dry and wrinkled, more or 
less discolored, and shows signs of general emaciation. Ac- 
cording to Neumann,* the epidermis is thinned ; the papillae 
of the corium are either altogether wanting, or are diminished 
in size; the pigment changes are irregular, and the hair fol- 
licles either well preserved or wasted. The hair is absent, 
or present only in the form of lanugo. The sebaceous glands 
always exhibit marked changes, which vary with the region. 

* Loc. cit. j p. 302 ; see also Hebra and Kaposi, vol. iii. p. 258. 



ALOPECIA. 391 

On the parts supplied with lanugo, they are either destroyed 
or are transformed into cysts (milium); where the hairs are 
large, they are found to be enlarged and distended. The 
sweat glands do not show structural alteration. 

In degenerative atrophy the connective tissue of the corium 
becomes metamorphosed into an infiltration of fine or coarse 
granular matter (granular degeneration), or into a vitreous, 
glassy, homogeneous mass (vitreous degeneration). Fatty 
and pigmentary degenerations may also occur. 

ALOPECIA. 

Alopecia is a condition of more or less complete baldness, 
resulting from a deficient growth of the hair, irrespective 

OF CAUSE. 

The varieties of alopecia are designated according to the 
causes which have occasioned the disorder, and also with the 
view of expressing their chief characteristic. 

Congenital Alopecia. — Absence of hair, either partial or 
entire, may exist as a congenital condition. Rare cases are 
recorded in which individuals have been born without hair; 
much more frequently, however, the hairs are scanty, or are 
developed only in certain localities. The amount of hair 
present at birth varies to a great extent; when deficient, it is 
usually found that sooner or later it commences to grow, 
although it may perhaps be scanty throughout life. In these 
anomalous cases an hereditary predisposition to deficiency of 
hair may usually be noted; some families are remarkable 
for the limited supply of this structure. 

Senile Alopecia — Senile Calvities — Baldness of Old 
Age. — This manifests itself by permanent loss of hair to- 
gether with general atrophy of the cutaneous tissues. It 
takes its origin, in the majority of cases, about the crown of 
the head. It is seen in old people, the exact time at which 
it shows itself varying considerably with individuals. Com- 
monly, the hairs turn gray, after which, in time, they become 
thin and dry and are cast off, either slowly or rapidly, not to 
be replaced. As is well known, this form of baldness affects 
men much more frequently than women; as yet no satisfac- 
tory reason for this has been suggested. The hair upon other 



392 ATROPHIES. 

regions of the body also suffers more or less atrophy, but rarely 
to the same extent, or so soon in life, as upon the scalp. 

The alterations in the cutaneous structures found in senile 
baldness have been studied by Neumann* and Pincus.f The 
changes are found to vary somewhat according to the ch To- 
nicity of the case and other circumstances ;- they usually 
consist in marked atrophy of the follicles, of the sebaceous 
glands, and of the skin itself. 

Idiopathic Premature Alopecia — Idiopathic Premature 
Baldness — Alopecia Simplex. — The process here may take 
place either rapidly, in the course of weeks or months, or, 
as is generally the case, slowly, through a period of years. 
The hairs may commence to come out at any period after 
puberty, although ordinarily the trouble does not begin to 
manifest itself until the age of twenty-five or thirty. 

The scalp throughout the process is seen to be apparently 
healthy, no scales or other signs of disease being at any time 
present. At first only a few hairs are from time to time cast 
off, and these are replaced immediately by a shorter and finer 
growth of hair. Later these in turn are shed, and are suc- 
ceeded by still finer hairs, — in fact, lanugo. In the course 
of time even these cease to appear, when complete baldness 
results. On the other hand, the affection at times may be 
partially arrested in its progress, and normal hairs may even 
be produced for a time ; but the improvement is not apt to 
be permanent, and sooner or later baldness in every way 
similar to senile baldness remains. 

This form of alopecia is exceedingly common. It occurs 
in both sexes, though much more frequently in men. As in 
the case of senile alopecia, it ordinarily begins about the 
region of the vertex, and extends itself forward to the fore- 
head, taking in on either side the space between the parietal 
protuberances.J 

Symptomatic Premature Alopecia.— Here are to be 
grouped a number of forms of baldness, more or less com- 
plete, caused by various diseases either local or general in 

* Loc. cit., p. 307. f Virchow's Archiv, Bd. xliii. 

% See an interesting article on this form of baldness, by Pincus, Berliner 
Klinische Wochenschrift, Nos. 4 and 5, 1875. 



ALOPECIA. 

their character. The loss of hair may be transitory or per- 
manent. Rapid shedding of the hair (defluvium capillorum) 
is apt to follow certain systemic diseases, as, for example, 
severe fevers; here it is usually a transitory affection. Ner- 
vous disorders, violent shocks to the nervous system, and 
mental distress, are also known to occasion loss of hair. 

Among the local causes, certain inflammatory diseases 
attacking the scalp — as erysipelas, psoriasis, eczema, variola 
— may be mentioned as giving rise to more or less alopecia; 
in these cases the hair may or may not return with the 
general health. Parasitic diseases, as tinea tonsurans, tinea 
favosa, are also common local causes of baldness; the con- 
dition may be temporary or permanent ; the new hairs return 
in a healthy state unless the follicle has been destroyed. 
Syphilis, leprosy, and other severe constitutional disorders 
also occasion alopecia. 

Syphilitic Alopecia. — Loss of hair may occur at two periods 
during the evolution of syphilis ; it is noted as one of the 
earliest symptoms, and again later, as a result either of cir- 
cumscribed specific infiltration and ulceration upon the scalp, 
or of the cachectic state into which the individual is apt 
to fall. It may be due to a local cause, as a disseminated, 
erythematous, papular, or pustular syphiloderm; or to a 
general cause, unaccompanied by appreciable lesions. The 
first variety of alopecia is encountered with the first cuta- 
neous manifestation. The hairs become dull, dry, brittle, 
loose, and are shed more or less uniformly from all parts of 
the head. The amount which comes out varies exceedingly; 
it may be so little as to be scarcely noticeable, or in such 
quantity as to cause partial baldness. The hairs upon other 
parts of the body may be likewise affected. In a short time, 
however, especially under treatment, they return ; permanent 
alopecia never occurs from this form. Loss of hair also takes 
place later in the course of the disease, which may or may 
not be reproduced. Permanent localized alopecia is usually 
the result of ulcerative lesions. 

Affections directly involving the sebaceous glands and hair 
follicles are to be regarded as the commonest causes of per- 
manent baldness. Chronic dry seborrhcea occupies a con- 



394 ATROPHIES. 

spicuous position in this connection ; it is a most fruitful 
source of alopecia, which takes place as the result of atrophy 
of the glandular structures. Lupus erythematosus attacking 
the scalp is also followed by permanently bald patches. 

Treatment. — The remedies employed for the relief of the 
forms of alopecia just enumerated, vary with the condition of 
the part and the cause of the trouble. Congenital alopecia 
is rarely so marked as to call for treatment; when, however, 
it exists to the extent of disfigurement, the surface may be 
stimulated by means of oily preparations and stimulating 
remedies. Senile baldness cannot be remedied. Simple 
premature alopecia requires an investigation into the prob- 
able cause. At times, attention to the general health, to- 
gether with the judicious use of alkaline or alcoholic lotions, 
followed by stimulating oils, may arrest the fall of hair. 

Symptomatic alopecia, the result of disease in other parts 
of the body, or of disease complicating the hairs and seba- 
ceous glands, is to be treated according to the nature of the 
primary affection. In inflammatory disorders of the scalp, 
as, for example, psoriasis, the inflammatory process is to be 
arrested by the means, both local and constitutional, recom- 
mended in speaking of these diseases. In parasitic affections 
the parasite is to be destroyed and the diseased hairs removed 
by epilation. The baldness resulting from severe constitu- 
tional disorders, as syphilis, should receive local attention in 
the form of oily preparations and lotions suited to the case, 
as well as the proper internal treatment. 

The management of alopecia following chronic seborrhcea 
of the scalp, will be found in connection with this disease. 
The external remedies and preparations, more or less modi- 
fied, referred to in the consideration of the treatment of 
alopecia areata and seborrhcea, may all be employed for the 
various forms of baldness. 



ALOPECIA AREATA. 395 



ALOPECIA AREATA. 

Syn. Area Celsi ; Alopecia Circumscripta ; Porrigo Decalvans ; Tinea 

)ecalvans. 

Alopecia areata is an atrophic disease of the hair system, 

[aracterized by the sudden appearance either of one or 

[ore, circumscribed, whitish, bald patches, varying in size 

^rom a coin to the palm of the hand, or of more or less 

universal baldness. 

The affection attacks the scalp, face, axilla?, pubis, and 
other hairy parts of the body. Its common seat is the 
scalp; next in frequency the beard in males is involved. 
The other regions are only rarely invaded. At times the 
whole body is affected, when there is apt to be entire absence 
of hair. 

The disease upon the scalp is observed to consist of one, 
two, or more patches of baldness. They are usually round- 
ish, often perfectly circular, and form markedly circum- 
scribed and conspicuous areas of disease. Occasionally they 
are irregular in outline, and assume an elongated or riband- 
shaped course. In size they vary from a small coin to the 
palm of the hand, but are usually about as large as a silver 
dollar. At times they coalesce and form patches involving 
the greater part of the side of the head. Their seat is very 
frequently about the parietal protuberance and behind the 
ear; the occiput as well as other localities may, however, 
also be attacked. The disease is very often unilateral. The 
baldness is generally complete, the area presenting a whitish, 
perfectly smooth, polished surface, without trace of hair. 
The hairs are, as a rule, uniformly absent. Around the 
border (after the patch has ceased enlarging) the hairs are 
quite firmly seated in their follicles, and exhibit no sign of 
disease ; it is seldom that they can be plucked without force. 
In other cases, a few small, broken hairs may be detected 
about the margin ; these resemble the stumpy hairs of tinea 
tonsurans, and have been considered by some as pointing to 
the parasitic nature of the affection. They are in reality par- 
tially diseased or atrophied hairs which have been broken off 
by mechanical means. Not infrequently after the disorder 



396 ATROPHIES. 

lias continued for some time, fine lanugo, or woolly hairs, 
may be seen to spring up over the surface. The color of the 
patch is usually pale or whitish, quite different from that of 
the healthy scalp. The follicles are no longer prominent, 
but are in great part closed and shrunken, so that the skin 
becomes thin and smooth, to such an extent that it resem- 
bles that of an old man. To the feel it is soft and pliable. 
It is always dry, and free both of desquamation and of seba- 
ceous matter. The patch is usually upon a level with the 
surrounding integument; it may, however, be slightly raised, 
or, in its later stage, somewhat depressed. Sensation is gen- 
erally preserved ; according to Neumann and others, it is at 
times diminished. 

The course of the disease is peculiar. It almost invariably 
makes its appearance suddenly and without premonition. 
Very often the hair is observed to come out during the night, 
the patient awaking to find unexpectedly a handful of loose 
hair and a bald patch. In other cases the fall is more 
gradual, several days or even longer elapsing before it has 
all been cast off; in these instances the disease is noticed to 
increase its area day by day until the process becomes ab- 
ruptly arrested, when no more hairs come out. The ultimate 
size of the area is usually soon determined, after which it 
rarely increases. It is this characteristic which distinguishes 
the affection from other forms of baldness. Where several 
patches exist, they will usually have been formed one after 
the other rather than at the same time, so that hair may be 
falling from one region or another for a week or longer. 
The disease may continue weeks, months, or longer, the time 
of its duration varying exceedingly. It, however, almost 
always terminates in recovery ; occasionally, it is said, the 
baldness is permanent. When repair sets in it usually pro- 
gresses rapidly, the hairs appearing first as lanugo and then 
growing as in the case of other new hair. 

The subjective symptoms are negative; neither itching, 
burning, nor pain is at any time present. The patient is 
first made aware of the condition by the quantity of loose 
hair and the appearance of the bald patch. 

Etiology. — The causes which produce the disease are not 



ALOPECIA AREATA. 397 

understood. It occurs in both males and females, but is 
more common in the latter. It attacks children much more 
frequently than adults. It is encountered among both the 
wealthy and the poor. It is non-parasitic in its nature. 
The origin is beyond doubt to be found in a peculiar func- 
tional nerve disturbance. It has been noted to follow neu- 
ralgias, sudden nervous shocks, and debility resulting from 
various causes. In many cases, however, no appreciable 
cause for the attack can be assigned. It is not contagious. 

Pathology. — The fall of the hair must be viewed as due to a 
state of perverted innervation. The suddenness of the attack, 
an important feature in the history of the disease, can only 
be accounted for by regarding the nervous system as at fault. 
The morbid influence which gives rise to the alopecia mani- 
fests itself with striking rapidity. The whole process, indeed, 
takes place in so short a time as to be altogether unexplain- 
able upon any other theory than that of want of nerve force. 
The white, shrunken, atrophic condition of the patch also 
points very strongly to the trouble being due to this cause. 

It is from a careful study of both hair and scalp that a cor- 
rect knowledge of the nature of the disease is to be gained. 
For microscopical examination of the hairs, either those 
which have fallen at first, or the short, stumpy, broken-off 
ones that may at times be found about the periphery of the 
patch, will be found suitable. They are seen to terminate 
abruptly in a pear- or club-shaped extremity, instead of the 
thick, long, spongy, luxuriant-looking bulb observed in 
healthy hairs. The bulb is contracted, shrivelled, and atro- 
phied, surrounded with only a scanty supply of sebum and 
epidermic cells. Its end is generally sharply defined, with a 
zigzag border. The root above the bulb retains its normal 
appearance, with the exception of being diminished in size. 
In the shaft, however, may be noticed, as the free end is 
approached, an even and gradual distention, terminating in 
an oval swelling, or bulging, close to the end of the hair, 
which tapers and finishes in a broken extremity. If the 
long hairs immediately about the border of the patch be 
examined, the same atrophied, shrunken bulb, the same 
feeble root, and the other peculiarities just referred to are 



398 ATROPHIES. 

observed, though in a less marked degree. This shrivelled, 
atrophied condition of the bulb is also seen in hairs that have 
lived their normal life, and, having been detached from their 
papillae, are thrown off; in one case it is disease, and in the 
other a natural process. In alopecia areata, instead of the 
normal death of the hair we have a sudden arrest of nutri- 
tion from some cause, and a rapid wasting and atrophy in 
consequence, due to disturbed innervation of the papillae. 

The bulging or oval distention of the shaft at its end may 
be explained as follows : the shaft not receiving its proper 
nourishment from the papilla, its extreme end suffers most; 
the filaments, not being sustained as usual, and losing their 
vitality, tend to separate, thus stretching the epidermic mem- 
brane and causing the appearance described. The fact that 
the filaments do separate is clearly demonstrated with a high 
power; moreover, this distention is quite constant and in the 
same position in the majority of cases.* 

Diagnosis. — Alopecia areata is most frequently confounded 
with tinea tonsurans; although the suddenness of the attack, 
the complete baldness, the absence of all desquamation and 
itching, the whiteness and remarkable smoothness of the 
patch, always enable it to be distinguished from this disease. 
Difficulty can arise only in old cases of tinea tonsurans, where 
the short, characteristic hairs have entirely disappeared ; 
but even here more or less desquamation invariably exists. 
Tinea tonsurans begins as a small patch and spreads grad- 
ually and often slowly about its periphery ; the whole process 
in alopecia areata takes place in a notably short time, after 
which it remains at a stand-still. A history of contagion is 
usually found in tinea tonsurans, resulting either from tinea 
tonsurans itself or from tinea circinata; alopecia areata is 
not contagious. The microscope is a valuable aid in cor- 
roborating the diagnosis, and should always be employed in 
cases of doubt; it determines the matter indisputably. The 
appearances found in the two diseases are very different : in 



* See a paper by the author in the Amer. Jour, of the Med. Sci., July, 1870. 
Also, an excellent article by Dr. Duckworth, St. Bartholomew's Hospital 
Keports, vol. viii. 



ALOPECIA AREATA. 399 

alopecia areata there are distinct signs of atrophy of the 
hair, especially noticeable about the root, unaccompanied 
by fungus; in tinea tonsurans the tricophyton parasite, con- 
sisting of chains of spores and threads of mycelium, both 
highly refractive of light, is always present in great abun- 
dance, and easy of detection. It is not impossible, in rare 
instances, that alopecia areata may exist upon the scalp at 
the same time with tinea tonsurans.* 

It may be known from favus by the absence of the char- 
acteristic yellow cups and crusts, and in the later stage of 
the disease by the absence of cicatricial tissue, which almost 
invariably results from protracted favus. 

Vitiligo is scarcely to be confounded with the disease 
under consideration, for it is an affection of the pigment 
system only; it is never accompanied by loss of hair. If it 
occur upon the hairy parts of the body, the hairs may be 
deprived of their color, but are not cast off. It is commonly 
a disease of the non-hairy parts. 

Alopecia areata may readily be diagnosed from other forms 
of alopecia by its peculiar train of symptoms. 

Treatment. — The results from the many remedies which are 
used in the treatment of this affection are exceedingly vari- 
able, their reputed success in many instances depending more 
upon the short duration of the cause which originally pro- 
duced the loss of hair, than upon their efficacy. Sooner 
or later, as a rule, recovery takes place spontaneously ; but 
on account of the disfigurement, as well as the anxiety on 
the part of the patient, it becomes necessary in all cases to 
hasten the desired end as much as possible. Both internal 
and external remedies may be used with advantage. A 
tonic treatment, consisting of iron, small doses of arsenic, 
cod-liver oil, fresh air, and exercise, should be prescribed 
in those cases where they seem required. 

The various external remedies which have been recom- 
mended are all more or less stimulant in their action, and are 
without specific effect, so that it matters little whether one or 
another be employed, provided the requisite amount of stim- 

* I think that much of the confusion concerning the nature of the disease 
may be accounted for by admitting this occurrence. 



400 ATROPHIES. 

illation be obtained. Among them alcohol, cantharides, the 
essential oils, glycerine, castor oil, carbolic acid, tar, iodine, 
turpentine, ammonia, salts of mercury, veratria, tannic acid, 
nux vomica, pepper, and sulphur may be mentioned as valu- 
able. They may be employed in the form either of ointments 
or of lotions, in sufficient strength to produce a stimulant or 
rubefacient effect upon the patch, and are to be applied 
once or twice daily, as occasion may require. Before making 
any of the above applications the scalp should be washed 
with water and soft soap, dried with a coarse towel, and 
brushed with a stiff brush until moderately stimulated. No 
fears need be entertained as to the production of increased 
baldness; for, after the patches have formed, the remaining 
hairs are firmly seated. 

Blistering the patches, by means of a cantharidal vesicating 
fluid, is frequently serviceable as a method of treatment; it 
may either be employed alone, or may be followed by some 
one of the substances mentioned. It should be repeated from 
time to time, according to the sensibility of the scalp. Alco- 
hol may be used either alone or with one of the stimulants; 
it constitutes the basis of almost all of the fluid formulae. 
Carbolic acid with alcohol has been frequently employed by 
the writer, and found useful. 

R Acidi Carbolici, fgss ; 

Alcoholis, f^iss ; 

01. Kicini, f^iii ; 

01. Amygdal. Amar., gtt. x. 
M. 

Cantharides, either in the form of powder with ointment, 
or as tincture, is likewise valuable. As an ointment it may 
be prepared in the strength of one or two drachms to the 
ounce; the tincture may be applied either in the officinal 
strength or diluted. Bulkley gives the following formula, 
which contains several desirable ingredients : 

B Tinct. Cantharidis, 

Tinct. Capsici, aa f^ss ; 

Olei Ricini, f^i ; 

Aq. Colognien., f^ii ; 
M. — Ft. liniment. 



ATROPHY OF THE HAIR. 401 

Aqua ammonise has long been esteemed as of service in 
the treatment of this affection. Wilson and Duckworth both 
speak well of it ; the former frequently employs it as follows: 

R Olei Amygdalae Dulcis, f^i ; 

Liquoris Ammoniae Fort., f|i ; 

Spiritus Rosmarini, f^iv ; 

Aquae Mellis, fSjii. 
M.— Ft. lotio. 

Erlach and Duckworth have of late again brought to notice 
oil of turpentine, which they consider a valuable application. 
It is to be rubbed into the patch with a stiff brush once or 
twice a day until the scalp becomes sensitive. Fox recom- 
mends vesication of the patches, after which the following 
lotion : 

R Tinct. Nucis Vomicae, f^ss ; 

Tinct. Cantharidis, f£vi ; 

Glycerin ae, f^ii ; 

Aceti Destillati, f^iss; 

Aquae Rosae, ad f^vj. 
M.— Ft. lotio. 

Hebra and Kaposi make use of the ethereal oils and of 
the stimulating alkaloids with alcohol. Rindfleisch states 
that he has had success with equal parts of tincture of pepper 
and glycerine. Tincture of iodine, repeatedly applied, has 
also been employed with satisfactory result. 

Prognosis. — As regards the time which the disease may 
continue, no opinion can be given. Occasionally recovery 
sets in a few weeks after the fall of hair; at other times 
months, or even years, will elapse before any sign of hair is 
visible. But it may be stated to the patient that sooner or 
later it will almost surely return. As a rule, no apprehension 
as to permanent baldness need be entertained. The indi- 
vidual should be encouraged to persevere in the treatment, 
with a view both to hasten the cure and at the same time to 
guard against despondency, which is apt to occur. I 

ATROPHY OF THE HAIR. 

Atrophic alterations in the structure of the hair take place 
as the result of various diseases of the scalp, as seborrhea 

26 



402 ATROPHIES. 

and the parasitic diseases; and also as the result of impaired 
nutrition following certain constitutional disorders, as syph- 
ilis, fevers, etc. In these cases the atrophy is symptomatic. 
It may attack a part or the whole of the hair substance, and 
is usually characterized by diminution of size, dryness, brit- 
tleness, and a tendency to separate and split up into its 
components. 

Idiopathic atrophy of the hair, independent of disease in 
other structures of the skin, also occurs, as in the following 
affections : 

Fragilitas Crlnium, Fragility of the Hair. This con- 
dition, so called by Mr. Wilson, is marked by a fragile and 
brittle state of the hair shaft. Two varieties are met with. 
The first and common form is that in which the shaft of the 
hair, either of the head or beard, shows irregularities and 
uneven formation in structure, being at one point thinner 
than at another. In addition to this imperfection, the free 
ends manifest a constant disposition to split up into filaments. 
This condition may occur as a slight abnormality, or, on the 
other hand, to such an extent as to render the crop of hair 
very defective. 

Another variety of fragility of the hair, first described by 
Beigel,* and designated by him " swelling and bursting of 
the hair," consists in the formation of a series of small, con- 
ical, bulbous swellings, situated at irregular intervals along 
the shaft of the hair. According to Beigel, and to Kaposi, 
who has encountered three cases, they possess a shining, 
somewhat transparent appearance, and look not unlike the 
ova of pediculi. The hairs readily rupture or break entirely 
off at the points of distention, and leave a bristly, brush- 
like stump, composed of jagged filaments. Kaposi suggests 
the name trichorexis nodosa for this disease. Devergie, 
of Paris, has also described and reported two cases of, proba- 
bly, the same affection, under the name of TRicoPTiLOSis.f 






* Sitzb. d. k. Akad. d. "W., Bd. xvii. p. 612, 1855 ; also Hebra and Kaposi, 
loc. cit., vol. iii. p. 244. 

f Annales de Dermatologie et de Sypbiligrapbie, No. 1, 1871, 1872. Trans- 
lated in the Amer. Jour, of Syph. and Derm., vol. iii. p. 254. 



ATROPHY OF THE NAIL. 403 

Two additional cases are reported by Billi.* The affection 
gives rise to considerable disfigurement. It is usually con- 
fined to the hairs of the beard, but may also occur on the 
scalp, as in Devergie's case. The cause is unknown ; it is 
not due to a vegetable parasite. 

The various forms of treatment useful in alopecia, in- 
cluding repeated shaving, do not appear to possess any in- 
fluence in arresting the process. Cutting the hair proved of 
benefit in one case. 

ATROPHY OF THE NAIL. 

The condition may be congenital; much more commonly, 
however, it exists as an acquired affection. It is character- 
ized by a deficient development or growth of the nail sub- 
stance, which is seen to be either smaller or thinner than 
normal; or brittle and split; or soft and crumbly, in a state 
of partial disintegration, according to the cause. The so- 
called " worm-eaten" condition of the nail, due to varied 
causes, is also at times of an atrophic nature. The color 
may be pale, whitish, and opaque ; or it may be dark. 

Atrophy of the nail may occur as a strictly local affection, 
or in consequence of some general disease, as syphilis. The 
fungi which prey upon the skin occasionally invade the sub- 
stance of the nail, causing deficient growth or even destruc- 
tion of the structure. 

Nails are also subject to injurious external influences, as 
happens in certain occupations, which interfere with their 
proper development. Certain diseases of the skin, as ec- 
zema and psoriasis, attack also the nails, producing atrophic 
lesions. 

* Giornale Italiano delle Malattie Yeneree e della Pelle. Milano, Agosto, 
1872. 



CLASS "VII. 
NEW GROWTHS. 

In this class are grouped a large number of important 
diseases, which, although differing in many instances in ap- 
pearance and external characters, consist pathologically of a 
new growth in the skin. 

The neoplasm may be made up of connective tissue, as in 
the case of keloid, molluscum fibrosum, and xanthoma; of a 
cellular deposit, as in lupus erythematosus, lupus vulgaris, 
syphilis, carcinoma, etc. ; of bloodvessels, as in vascular 
nsevus ; or of lymphatics or of nerves, as in lymphadenoma 
and neuroma. 

The neoplasmata, clinically, are either benign or malignant 
in their nature. The connective-tissue growths may be said 
to be benign ; while certain of the cellular formations, as, for 
example, leprosy and cancer, are characterized by malignancy, 
completely destroying the tissues which they attack, and at 
times life. 

According to their nature are they unattended by or accom- 
panied with pain. The majority are not of a painful nature. 
They pursue a chronic course, ordinarily lasting throughout 
life, unless relieved ; in some instances, as in syphilis and 
cancer, they run a comparatively rapid course. In many 
instances they are amenable to operative interference. Their 
pathology has been already referred to. 

KELOID. 

Syn. Kelis: Kelos : Germ., Der Knollenkrebs ; Fr., Cancroide ; Cheloide. 

Keloid is a connective-tissue new growth, characterized 
by an irregularly shaped, variously sized, sharply defined, 
elevated, smooth, hard, somewhat elastic, reddish formation, 
accompanied by more or less pain upon pressure. 

Symptoms. — The disease commences as a small, pea or bean 

404 



KELOID. 405 

sized, nodule firmly implanted in the skin, quite pale in 
color, resembling a cicatrix. It increases in size, as a rule, 
very slowly, years often being necessary for its development 
as commonly encountered. The form of the tumor is 
always peculiar. It is made up usually of a central portion 
or body, together with several or numerous prolongations or 
claws, extending out into the healthy skin; at other times 
it consists of a circumscribed growth terminating abruptly 
against the sound tissues. The shape of the keloid tumor 
is exceedingly variable ; it may be oval, elongated, star- 
shaped, cylindrical, crab-shaped, or even in the form of 
streaks and broken lines. It is indeed remarkable for the 
irregularity of its shape. In size it likewise varies; it may 
be quite small, bean sized, or as large as a hand. Usually 
it is several inches in diameter. The outlines of the growth 
are always well defined, the disease appearing to be half 
imbedded in the tissues. It is more prominent about its 
centre, tapering off towards its periphery. It is elevated ; 
very often as much as several lines. Its surface is smooth 
and usually devoid of hair. Taken between the fingers it 
has a solid, dense, slightly elastic feel. Its color is pinkish, 
or reddish; it generally has a shining appearance. 

One, several, or many growths may exist; commonly, 
however, but one is present. The usual seat for them is 
upon the trunk, more particularly about the sternal region. 
Occurring here the tumor is apt to extend itself laterally, 
parallel with the ribs, sending out its prolongations in all 
directions. Keloid is also encountered upon the mammae, 
neck, ears, arms, and other regions. More or less pain and 
itching usually accompany keloid; neither of these symp- 
toms, however, is by any means constant. Pain is more 
especially noticeable upon pressure. 

The course of the disease may be either rapid or slow ; 
having attained a certain growth it is very apt to remain 
stationary. It is never attended with ulceration. It usually 
exists throughout life; occasionally, very rarely, it under- 
goes spontaneous involution. 

Etiology. — Keloid may arise spontaneously, in which case 
it is termed spontaneous keloid. It may also spring up at the 



406 NEW GROWTHS. 

site of cicatrices, when it is called cicatricial keloid. The differ- 
ence between these two forms is one depending alone upon 
the cause which has occasioned their appearance; micro- 
scopically they are identical in structure. 

The disease is encountered in both sexes, and usually 
appears in early adult or middle life. It is very much more 
common in the colored than in the white race. No cause is 
to be ascribed to the spontaneous variety of the disease. 
Cicatricial keloid follows various injuries to the skin, it being 
understood that there exists in the individual a predisposition 
to its development. It is frequently met with as the result 
of burns by fire or chemicals, cuts, flogging, and wounds of 
all kinds.* 

Pathology. — Studies relating to the anatomy of keloid have 
recently been made by Langhans,f Warren, J Kaposi, § 
myself,|| and others. The growth is made up of a dense, 
fibrous mass of tissue, whitish in color, having its seat in 
the coriurn. Microscopic examination shows the horny and 
mucous layers of the epidermis to be normal ; likewise the 
papillae. The whole corium is occupied by a new formation, 
consisting of bands of connective tissue, arranged more or 
less parallel to the surface of the growth ; here and there 
they run vertically. The fibres are closely packed together 
and form a dense, solid mass. Cells are rarely encountered, 
excepting along the course of vessels, especially the arteries, 
where they may be seen in layers about the walls of the 
vessels ; they are nucleated and spindle-shaped, and are to 
be observed to best advantage in the more recent portions 
of the growth. It has been clearly shown by Warren, of 
Boston, that the disease has its starting point in the walls 
of the vessels, the cells referred to accumulating and in time 
becoming metamorphosed into connective tissue. 

Diagnosis. — The symptoms of keloid are so striking in 

* A remarkable growth of cicatricial keloid is reported by Dr. F. F. 
Maury, Photographic Eeview of Med. and Surg., Oct. 1870. 
f Virchow's Archiv., B. xl. p. 334. 

% Sitzungsbericht der k. Akad. der Wissenschaft, 1868. 
\ Loc. cit., vol. iii. p. 281. 






MOLLUSCUM FIBROSUM. 407 

character that no difficulty, as a rule, is experienced in the 
diagnosis. It is most liable to be confounded with simple 
cicatrix, from which, however, it may be known by its color, 
outline, elevation, and consistence, and frequently by the 
presence of pain ; the history will also be of assistance in 
arriving at an opinion. 

Treatment. — This is usually unsatisfactory, for operative 
interference, either by means of caustics or the knife, is 
almost invariably followed by return of the disease, and fre- 
quently in an exaggerated form. Various caustic remedies 
have been employed, with, however, as a rule, unfavorable 
results. Caustic potash has proved of value in certain cases, 
and offers the most efficient remedy if an operation be de- 
manded; this should never be entertained if the disease is 
still increasing. To allay the pain which is at times present, 
hypodermic injections of morphia into the part are particu- 
larly useful. Chloroform and anodyne ointments may also 
be prescribed for the same purpose. 

Internally, both the iodide of potassium and arsenic have 
been recommended; it is doubtful, however, whether they 
exercise any influence over the growth of the disease. Qui- 
nine is said to be of use in arresting the paroxysmal pains; 
this also will be found to be very uncertain in its action. 

Prognosis. — Spontaneous involution occasionally occurs; 
but this event is rare. Not infrequently having attained a 
certain size the tumor ceases to develop, a course, however, 
which cannot be predicted. Its course, as a rule, is that of 
progression, attended at times by temporary arrest of devel- 
opment. 

MOLLUSCUM FIBROSUM. 

Syn. Fibroma Molluscum : Molluscum Simplex ; Molluscum Non-conta- 
giosum ; Molluscum Pendulum. 

Molluscum fibrosum is a connective-tissue new growth, 
characterized by sessile or pedunculated, soft but firm, 
roundish, painless tumors, varying in size from a split pea 
to an egg or larger, seated in and beneath the skin. 

Symptoms. — These growths occur either singly, or, as is 
more apt to be the case, in large numbers, when they are 
observed to occupy the greater part of the body. They 



408 NEW GROWTHS. 

assume various forms and shapes upon the same individual ; 
at times they are dome-shaped, and are seated in the skin 
itself or in the subcutaneous tissue; while in other cases 
they are pedunculated, club-shaped, and hang from their 
pedicles. In consistence they are uniformly soft, but when 
taken between the fingers are usually found to have a cer- 
tain amount of body ; the larger ones have a somewhat 
elastic, fibrous feel. The skin covering them is smooth and 
normal in color, although it will be observed to differ some- 
what in its structure according as the tumor is large or small, 
sessile or pedunculated. The skin covering them may be 
loose or stretched ; hypertrophiejd or atrophied. 

Their size varies exceedingly. Where multiple they are 
usually pea or cherry sized, with here and there larger ones 
varying from a walnut to a large pear. If single they are 
apt to be pedunculated and to attain considerable size, often 
weighing many pounds. As to numbers, when multiple 
they ordinarily exist in hundreds, occupying the greater 
part of the surface, without regularity of distribution ; they 
have preference, however, for the softer tissues, and conse 
quently develop extensively about the trunk. They are 
never attended with pain, although at times their great 
size and weight render them a source of extreme discom- 
fort.* 

They may make their appearance at any time during life, 
often in childhood, and grow more or less rapidly, either 
steadily or interruptedly, throughout life. Having attained 
a certain size they usually remain stationary; large, pendu- 
lous tumors occasionally ulcerate, as in the case of other 
large, heavy growths. 

Etiology. — The disease is encountered in both sexes and in 
various races. The cause is unknown. Hebra has made 
note of the fact that all of the patients with this affection 
who have from time to time come under his notice, were 
remarkably stunted in physical as well as in mental develop- 

* A well-marked example of the disease, with portrait, reported by Dr. 
Oeterlony, of Louisville, may be found in the Archives of Dermatology, 
July, 1875. Another case, with portrait, has been published in the same 
journal, April, 1876, by Dr. Wigglesworth, of "Boston. 



MOLLUSCUM FIBROSUM. 409 

ment. The observation has been verified by others, and by 
myself.* The general health of the patient does not suffer. 
The disease may be inherited, and may, moreover, manifest 
itself in several children of the family, f 

Pathology. — The internal structure of molluscum fibrosum 
will be found to differ somewhat as the tumor is small or 
large, recent or old. A section made through the loug axis 
of one which is fully developed, shows it to consist of a 
whitish, fibrous mass, from which upon pressure a small 
quantity of yellowish fluid can be made to exude. The 
growth is dense and compact about its base, and is here seen 
to be made up of coarse, irregular bands of fibrous tissue. 
In the centre it is quite soft and pulpy, while about the 
periphery the fibres are finer and partake more of the struc- 
ture of the corium. No Hues, however, mark these differ- 
ences. These tumors cannot be enucleated, for they are 
firmly bound down by their pedicles to the subcutaneous 
and fatty tissues. Old growths, which have assumed a dense 
fibrous character, are, as a rule, less adherent to the corium, 
and may, therefore, more readily be dissected out. The 
attachments at the base, however, are always secure. Under 
the microscope small, recent tumors are observed to be made 
up of gelatinous, young connective tissue. The cells are to 
be seen more particularly about the periphery, and are 
traversed by bundles of fine fibrillse. Older tumors consist 
in great part of firm, dense, fibrous tissue, closely packed 
together. When large, the tumors are quite vascular about 
the bases. According to Rokitansky aud others, molluscum 
fibrosum starts in the connective tissue of the deeper layers 
of the corium. Virchow holds that they may also take their 
origin in the subcutaneous connective tissue. 

Diagnosis. — No difficulty, as a rule, presents itself in arriving 
at a correct diagnosis. The tumors are to be distinguished 
from those of molluscum sebaceum by the fact that they do 
not possess any depression or aperture upon their tops; they 

* Phila. Med. Times, March 18, 1876; also in other cases. 

f See a recent paper, reporting two cases, by Dr. J. E. Atkinson, of Balti- 
more, New York Med. Jour., Dec, 1875; also a report of three cases by 
Dr. John Murray, Lancet, March 22, 1873. 



410 NEW GROWTHS. 

are closed and do not permit of anything being squeezed 
out. They are, moreover, situated distinctly in and beneath 
the skin, which structure appears to be normal, whereas 
the sebaceous tumors are superficial, and stand forth promi- 
nently, covered by skin which is always thin and stretched. 
The history and course of these two affections are so different 
as scarcely to permit of confusion.* 

They are not to be confounded with multiple neuromata 
of the skin, from which they may be known by the absence 
of pain ; nor with lipomatous growths, which are always 
remarkably soft and generally lobulated in structure. 

Treatment. — When not too numerous, they may be excised 
by the knife, as in the case of other tumors of a similar 
nature. If large and pedunculated, they may be ligated, or 
treated by the galvanic cautery. Hemorrhage should be 
guarded against. 

Prognosis. — The affection is one which lasts throughout life. 
The tumors either continue to increase in size and number, 
or, having attained a certain development, become arrested 
in their growth and production. 

XANTHOMA. 

Syn. Xanthelasma; Yitiligoidea. 

Xanthoma is a connective-tissue new growth, character- 
ized BY THE FORMATION OF YELLOWISH, CIRCUMSCRIBED, IRREGU- 
LARLY SHAPED, VARIOUSLY SIZED, NON-INDURATED PATCHES OR 
TUBERCLES. 

Symptoms. — Two varieties of the affection are encountered ; 
the macular and the tubercular. In the macular, or flat 
variety, the disease consists of pea-sized or larger, usually 
elongated or linear patches, having their seat in the corium. 
They are on a level with the surrounding skin, and have 
the appearance of being inlaid. They are sharply defined 
against the sound skin; possess a smooth surface; and are 
soft and apparently normal in texture to the touch. In shape 
they are either roundish, oval, or elongated ; occurring upon 
the eyelids, their favorite locality, they commonly assume 

* For further aid in the diagnosis, consult Molluscum Sebaceum, p. 121. 



XANTHOMA. 411 

the form of semicircular bands, a couple of lines in width, 
extending from one canthus to the other. In color they are 
yellowish, the shade varying from a bright canary or lemon 
to orange. One, two, or more patches may exist, situated 
either closely together, as about the eyelids, or in different 
regions. They begin as small, pin-head or pea sized lesions, 
and increase in size very gradually and slowly in the course 
of years; very frequently two or more of these small patches 
coalesce. The common seat of this variety of xanthoma is 
about the eyelids, especially the upper; it is also seen occa- 
sionally upon other portions of the face, as well as upon the 
body. The patches give rise to no pain, and often to no 
inconvenience beyond the disfigurement. 

The tubercular form of the affection shows itself as pin- 
head, pea, or larger sized, roundish, raised patches or tu- 
bercles. In general characters the growths do not differ 
materially from those of the flat variety. They are, how- 
ever, seldom encountered upon the eyelids; they incline to 
develop upon the neck, body, and extremities. I recently 
saw a case, with Dr. R. W. Taylor, of New York, in which 
they were present over the arms, in the form of numerous 
roundish, pea sized, elevated, golden-yellow tubercles. The 
patient was a stout, healthy woman, about thirty-five years 
of age. 

Xanthoma always develops very gradually; runs an ex- 
ceedingly slow course; and continues through life. 

Etiology. — The causes are obscure. In a number of the 
reported cases jaundice has been noted either as having oc- 
curred previously or as being present; the connection, how- 
ever, between the two diseases is by no means determined. 
I am unable to see any valid reason, beyond the similarity of 
the color, for associating the two conditions. Hutchinson* 
and Kaposif have both discussed this subject at length. The 
affection is more common in women than in men ; it has not 
been observed in children. 

Pathology. — Examinations of pieces of excised xanthoma 
have been made by numerous investigators, with different 

* Medico-Chir. Trans., 1871. f Loc. cit., vol. iii. p. 351. 



412 NEW GROWTHS. 

results.* In a patch recently excised from the upper eyelid 
by Dr. Strawbridge, of this city, I found the structure, im- 
mediately after removal, soft and flaccid, resembling a piece 
of normal skin ; section through the centre of the mass 
showed the tissue to be of a yellowish-white color. The dis- 
ease had its seat in the corium, and consisted of connective 
tissue, the cells of which had undergone fatty degeneration ; 
oil globules and fat were present ; the latter deposit gave the 
formation its peculiar yellow color. This result agrees with 
the examinations of the majority of those who have recently 
described the anatomy of the disease. 

Treatment. — If interference is called for, the only plan of 
treatment is that of excision, which may be readily and, as a 
rule, satisfactorily accomplished. In order to avoid ectropion, 
when the affection is upon the eyelids, which, it should be 
stated to the patient, is liable to occur, care should be taken 
not to carry the incision around the patch too deeply into the 
tissues. After removal the edges are to be brought together 
by stitches, and the case treated as an ordinary wound. 

RHINOSCLEROMA. 

Rhinoscleroma consists op a circumscribed, irregularly 
shaped, flattened, tubercular growth, the size of a finger 
nail or larger, remarkably hard and dense in structure, 
somewhat painful, having its seat about the region of the 

NOSE.f 

Symptoms. — The growth, which may be either roundish or 
angular in outline, is always well defined by an abrupt ridge 
or line of demarcation, beyond which the tissues appear in 
every way normal. It is more or less elevated above the 
surrounding skin, and usually possesses a flattened, plate- 
like, somewhat uneven surface, caused by the presence of 
variously sized, isolated or aggregated nodules of which the 
mass is composed. These prominences are either of the color 

* See Kaposi, loc. cit., vol. iii. p. 355. 

f This affection was first described by Hebra and Kaposi in 1870 (Khino- 
sclerom, Wiener Med. Wochenschrift, No. 1, 1870). The author is indebted 
to Prof. Hebra for the opportunity of observing two examples of the disease. 






RHIXOSCLEROMA. 413 

of the normal skin, or are reddish or brownish. The tissues 
over the patch are firmly bound down, as in the case of 
scleroderma, and cannot be taken up between the fingers; 
the epidermis is dry, with here and there fissures which 
secrete a small quantity of viscid fluid, which forms into 
yellowish, adherent crusts. The growth is exceedingly dense, 
and may be compared to the hardness of wood or stone. 
Upon pressure it is slightly elastic, and at the same time 
painful; at no stage does it appear either inflammatory, 
swollen, or cedematous. 

The disease is confined to the nose and contiguous parts. 
Its course is remarkably slow, lasting over a period of years. 
As it progresses the induration becomes very marked, the 
alse narrowing in calibre until occlusion takes place. The 
nodules or tubercles do not change in their structure, even 
though they exist for years. 

Etiology. — The causes are unknown. It is encountered in 
both men and women, usually at middle age. 

Pathology. — Kaposi* remarks, " On cutting into one of the 
tubercles of rhinoscleroma, one is surprised at the ease with 
which the knife makes its way in comparison with the hard- 
ness which is apparent to the touch. The cut surface is of 
a pale red color, uniformly and finely granular, and bleeds 
freely." 

The microscopic anatomy has been carefully studied by 
Kaposi, and Geber.f The former observer gives the fol- 
lowing result of his examinations. The epidermis and rete 
were normal. The papillae were longer than usual, their 
connective-tissue framework existing in the form of a finely 
fibrillated, small-meshed network; their vessels were scanty 
and thinner than usual. " The connective tissue of the vas- 
cular layer also only consisted of a narrow network of deli- 
cate, thin, pale fibres. This network of the vascular layer 
of the papillae was filled with small cells closely packed 
together, the cellular infiltration, here and there, extending 
deeply into the corium, which was uniformly dense through- 



* Loc. cit., vol. iv. p. 7. 

f Archiv fur Derm, und Syph., 1872, 4 Heft. 



414 NEW GROWTHS. 



, 



out, the vascular stratum and the papillae being especiall 
crammed full of cells. The cells were smaller, especially in 
the protoplasm, than the so-called granulation cells usually 
are, as met with in acute or chronic inflammation of the 
skin, and also in places where a new growth of connective 
tissue is taking place. The nuclei of the round cells were 
small and refracted light feebly, and were finely granular. 
The cells appeared to be simply lodged in the delicate con- 
nective-tissue stroma of the papillae and the upper layers of 
the corium, and could easily be removed by manipulation. 
The deeper layers of the corium showed a dense connective- 
tissue felt." It is further stated that the cells were well 
preserved, and had a sharp outline and distinct nuclei, dif- 
fering in this respect from the degenerative cells of lupus 
and syphilis. The growth must be viewed as allied to the 
small-celled or granulation sarcomata. 

Diagnosis. — The location of the disease, the extreme hard- 
ness of the patch, the line of demarcation surrounding it, 
the alteration in the shape of the nostrils, together with its 
slow course, will usually serve to distinguish it from other 
affections. It may be confounded with syphilis, keloid, and 
epithelioma, but upon investigation will be found to differ 
from these diseases in many particulars. 

Treatment. — The disease calls for interference, for, if per- 
mitted to increase, occlusion of the nostrils will occur. It is 
to be destroyed by means of caustics, the nitrate of silver or 
potash stick being the best remedies. No inflammatory 
action is set up, nor does the part ever assume a malignant 
character in consequence of the operation. Cauterization, 
however, is attended with but temporary benefit, for the dis- 
ease tends to return after a time. 

Prognosis. — This is never favorable. It is exceedingly ob- 
stinate, and, without treatment, usually continues a lifetime. 
Under the repeated use of remedies great relief may be ex- 
perienced. 



LUPUS ERYTHEMATOSUS. 415 



LUPUS ERYTHEMATOSUS. 

Syn. Lupus Erythematodes ; Seborrhoea Congestiva ; Lupus Superficialis; 
Lupus Sebaceus; Germ., Lupus Erythematosus ; Fr., Scrofulide Erythema- 
teuse ; Erythema Centrifuge. 

Lupus erythematosus is a chronic disease, characterized 
by one or more circumscribed, roundish or irregularly shaped, 
variously sized, reddish patches, covered with thin, grayish 
or yellowish, fatty, adherent scales. 

Symptoms. — The disease begins either in the form of one 
or two, usually roundish, circumscribed patches, which, en- 
larging upon their peripheries, increase indefinitely in size ; 
or, in the form of two or three or a number of isolated 
patches, which gradually approach one another, and coalesce 
to make one or more larger patches. The lesions, at first, 
are small, pin-head or pea sized, erythematous spots, which 
ordinarily make their appearance slowly. They are usually 
circumscribed from their commencement, exhibiting a 
slightly elevated border, covered with fine, grayish or yel- 
lowish scales. The patches, as a rule, extend very gradu- 
ally ; at times, however, they assume considerable size in 
the course of a month or two. 

When fully developed, lupus erythematosus is seen to con- 
sist of one, two or a number of patches, varying in size from 
a split pea to a silver dollar or the palm of the hand, having a 
distinctly defined, slightly raised border. In shape they are 
usually roundish or oval ; occasionally they are irregular in 
outline. In color they are reddish, the shade varying from 
a deep pink to a deep red. The surface is invariably covered 
with fine, thin, grayish or yellowish, fatty, remarkably adhe- 
rent scales. These are usually scanty ; at times, however, 
they are so abundant as to form a yellowish, sebaceous crust, 
like that met with in seborrhoea of the face. They are firmly 
attached to the openings of the sebaceous glands. The fol- 
licles are noted to be widely distended and patulous. They 
are seen to play a conspicuous part in the disease. The patch 
spreads upon its margin, the border being always well de- 
fined, while the central portion usually shows a paler color, 
some depression, and a tendency to atrophic change. After a 



416 NEW GROWTHS. 

variable time the patch attains a certain size and is apt to 
remain stationary. There is never any moisture or discharge 
in connection with the disease. 

The usual seat of the affection is upon the face. The 
cheeks, especially just below the eyes, and the bridge of the 
nose are most frequently attacked. When these regions 
are at the same time invaded, the symmetry is ordinarily so 
marked that the eruption presents an appearance not unlike 
the form of a bat or butterfly with outspread wings.* The 
red of the lips, ears, scalp, back, and other parts of the body 
may likewise be involved. The disease is usually very dis- 
figuring. 

The course of the disease is notable for its chronicity; it 
may exist years, increasing from time to time by repeated 
attacks. Now and then it progresses much more rapidly. 
Ultimately the process ends in the formation of a whitish or 
yellowish, punctate, soft, cicatricial tissue, which may be 
either very superficial or, on the other hand, quite deep 
seated. 

The subjective symptoms are variable, and depend upon 
the activity of the disease ; at times there is great burning and 
itching ; in other cases but little discomfort is experienced. 
The general health is usually good, and ordinarily remains 
so. According to Kaposi, erysipelas, adenitis, and subcuta- 
neous swellings of a peculiar character may complicate the 
disease. I have never encountered these symptoms. 

Etiology. — The causes are obscure. It is one of the rarer 
diseases of the skin. Females are found to be much more 
liable to it than males. It seldom occurs before adult age, 
differing in this respect from lupus vulgaris. It attacks per- 
sons of all temperaments, but is most commonly met with 
in those with light skin and hair. It is observed notably 
upon those who are subject to disorders of the sebaceous 
glands. Not infrequently it originates in causes similar to 
those which produce seborrhcea ; it is well known that lupus 
erythematosus may, and often does, start as a simple, local- 
ized seborrhcea. 

* See Plate C, Lupus Erythematosus, Part I., in the author's Atlas of Skin 
Diseases. 



LUPUS ERYTHEMATOSUS. 417 

Pathology. — It is a cellular new formation, preceded by and 
attended with marked hyperemia, having its seat, as a rule, 
primarily about the sebaceous glands and follicles. The sweat 
glands are said to be also at times primarily involved. Hebra 
as early as 1845 pointed out that the disease had its chief seat 
in the sebaceous glands, and gave it the name of" seborrhoea 
congestiva." Since then, Neumann, and later, Geddings,* Ka- 
posi, and others, have made repeated microscopical sections, 
with the following result. When the disease is fully de- 
veloped there is marked cellular infiltration in the papillae 
and throughout the connective tissue of the corium, es- 
pecially noticeable about the glands and follicles. This in- 
filtration is very abundant, and at times is seen to obliterate 
completely the distinctive character of the parts invaded. The 
papillae are observed to be of abnormal shape and size, usu- 
ally very much enlarged ; at times they are but imperfectly 
defined; the walls of the sebaceous glands and hair follicles 
are thickened by the presence of both connective tissue and 
cells; while in some cases the whole tissue of the corium is 
filled with this deposit, destroying all trace of its normal 
character. If atrophy now occur, the infiltration appears to 
undergo waxy metamorphosis, showing itself in the form of 
a yellowish cicatricial tissue, containing miliary deposits or 
fatty molecules. In this stage, all the structures of the skin 
become greatly altered. 

Diagnosis. — When fully developed, the patch offers such a 
striking picture that there is little danger of confounding 
lupus erythematosus with any other disease. The region 
attacked, almost always the face, and usually the cheeks and 
nose; the circumscribed, roundish, red patch with a defined 
border; the involvement of the sebaceous glands, and the 
adherent, grayish or yellowish, fatty scales; the slow course 
of the disease; all point directly to lupus erythematosus and 
no other affection. 

It is to be distinguished from lupus vulgaris by the absence 
of papules, tubercles, and ulceration. In lupus erythema- 
tosus the sebaceous glands are seen to be enlarged and 



* Amer. Jour, of the Med. Sci., July, 1869. 
27 



418 NEW GROWTHS. 

disordered; they are not in any degree affected in lupus 
vulgaris. The lesion in lupus vulgaris consists in the de- 
posit of numerous minute, pin-head sized aggregations of 
new cellular material, seated at first subcutaneously ; later 
in the course of the disease, papules, tubercles, and other 
hypertrophic formations, followed by ulceration, take place. 
Lupus erythematosus rarely shows itself before adult life; 
lupus vulgaris usually appears in childhood. Lupus erythe- 
matosus is a superficial disease throughout its course; lupus 
vulgaris is deep seated and attended sooner or later with 
ulceration and disfiguring cicatrices. . 

Psoriasis may at times bear some resemblance to lupus 
erythematosus, but may always be distinguished by its acute 
course, as well as by other symptoms peculiar to it. Acne 
rosacea may be known by the diftuseness of the disease; in 
lupus erythematosus the patch is markedly circumscribed 
and surrounded with a border. The disease cannot well be 
mistaken for syphilis; its characteristic features, history, and 
course, will prevent such an error. 

Treatment. — The disease is, as a rule, remarkably intrac- 
table and rebellious to the influence of therapeutics. 

The internal remedies are to be selected to meet the needs 
of the case; at times patients appear to be in otherwise perfect 
health, in which case external treatment alone is to be relied 
upon. The general condition, however, is always to be care- 
fully investigated, and, if at all impaired, vigorously treated. 
In many cases the preparations of iron, iodine, and arsenic, 
may be used with advantage. Iodide of potassium may not 
infrequently be prescribed with benefit. Diet in some cases 
is a matter of importance ; it should be of the best quality and 
generous, consisting largely of animal food. In this con- 
nection cod-liver oil is to be referred to. It may be given, in 
full doses, in the majority of cases. In many instances it will 
be found to exert a marked influence upon the disease, 
especially in those cases where the health is poor and there 
is a tendency to impaired general nutrition. Hygiene, fresh 
air, exercise, bathing, are all to be employed as adjuvants in 
the treatment. 

The external treatment will, however, as a rule, be found 



LUPUS ERYTHEMATOSUS. 419 

to be of the greatest value. Many remedies have been 
suggested and tried, all of them with variable success. 
Stimulating and caustic applications are followed by the 
best results. Among the remedies employed, soft soap occu- 
pies a prominent position. In mild cases the disease may 
occasionally be relieved by this means alone. In combi- 
nation with alcohol, equal parts, it is even of greater value. 
The patch is to be well rubbed and washed with it until all 
the scales have been removed, when a weak glycerine lotion 
or simple ointment may be applied ; in some cases it is expe- 
dient to make no after application. The washings are to 
be repeated twice daily, and to be continued for some time. 
Apart from the remedial effect, the soap serves as an admi- 
rable means of cleansing the patch for further treatment. 

Mercurial ointment is of great service in many cases; it is 
to be prepared as a plaster and to be applied continuously. I 
have obtained good results from it. Care should be observed 
that ptyalism is not induced. Ammoniated mercury oint- 
ment, from ten grains to a drachm to the ounce, as may best 
suit the case, may also be employed. Sulphur may at times 
prove serviceable; it should be prescribed in the form of an 
alcoholic solution or as an ointment, a drachm to the ounce. 
Carbolic acid has been occasionally followed by satisfactory 
results ; it is to be employed either pure or diluted with 
water, equal parts. Its application is painful. 

Tar is one of the most reliable remedies; it may be used 
pure or diluted, either in the form of a lotion or as an oint- 
ment. A mixture containing equal parts of oil of cade, 
alcohol, and soft soap, to be rubbed into the patch morning 
and evening, is often an exceedingly valuable remedy. Tinc- 
ture of iodine, alone or with glycerine, painted twice daily 
upon the patch until a crust has formed, as recommended by 
Hebra, will at times act favorably. Anderson also speaks 
well of this treatment, and gives the following formula: 
Iodine and iodide of potassium, of each half an ounce; 
glycerine, one drachm. The part is to be painted daily 
until a thick coating forms, or till the application becomes 
painful, when it is to be omitted until the effect of the 
previous applications has passed away. 



420 NEW GROWTHS. 

Stronger application?, caustics, are often demanded in 
obstinate cases; they should, however, never be used until 
milder remedies have been tried. A solution of caustic 
potash in water, equal parts, or one part to three or six of 
water, may be used when other remedies have failed. It is 
to be applied by means of a charpie brush, care being taken 
not to permit its action to extend too deep into the tissues ; 
vinegar or dilute acetic acid should be used immediately 
afterwards, to counteract this tendency.* 

The after dressing should consist of water, glycerine, or 
a simple ointment. Dr. Anderson reports favorable results 
in certain cases from the repeated use of a cantharidal 
blistering fluid. The acid nitrate of mercury, corrosive 
chloride of mercury, chromic acid, nitric acid, chloride of 
zinc, nitrate of silver, arsenic, red iodide of mercury, in 
various strengths, have all been used, but without notable 
success. They should always be employed cautiously, on 
account of their very destructive properties, as well as on 
account of the pain they occasion. Eecently Hebra and 
others have successfully made use of the "curette" or 
"scoop" (as originally suggested by Volkmann, of Halle, for 
lupus vulgaris) in the treatment of lupus erythematosus. 
Wigglesworth, of Boston, speaks well of it.f 

Multiple scarification, or puncturing, as recommended by 
Volkmann for lupus vulgaris, is said by Yeiel and Kaposi to 
have a corresponding effect in lupus erythematosus. (See the 
treatment of lupus vulgaris.) 

Prognosis. — This should be guardedly expressed, more par- 
ticularly so if the disease has existed for any length of time. 
When fully developed it almost always proves one of the most 
troublesome and stubborn of the cutaneous diseases. Occa- 
sionally it yields more kindly to treatment. The result will 
depend upon the extent of the disease, its distribution, the 
number of patches, the activity of the process, its duration, 

* For further remarks upon the use of caustic potash, see the treatment of 
epithelioma ; for other caustics, lupus vulgaris. 

f See an interesting paper by Dr. Wigglesworth, describing the curette 
and the manner of its employment. Boston Med. and Surg. Jour., Feb. 
10, 1876. 



LUPUS VULGARIS. 421 

and the general condition of the patient. Relapses are very 
liable to occur. 

LUPUS VULGARIS. 

Syn. Lupus Exedens; Lupus Vorax ; Noli Me Tangere; Germ., Fres- 
sende Flechte ; Fr., Herpes Esthiomenos ; Dartre Kongeante ; Scrofulide 
Tuberculeuse ; Esthiomene. 

Lupus vulgaris is a chronic disease, characterized by vari- 
ously SIZED AND SHAPED, REDDISH OR YELLOWISH PATCHES CON- 
SISTING OF PAPULES, TUBERCLES, OR FLAT INFILTRATIONS, WHICH 
USUALLY TERMINATE IN ULCERATION AND EXTENSIVE CICATRICES. 

The disease presents a number of appearances as it as- 
sumes one form or another, and as it is seen in the various 
stages of its development. It commonly begins in the form of 
numerous, small, grouped or disseminated points, situated 
immediately beneath the epidermis. These are reddish or 
somewhat yellowish in color, and have their seat within the 
structure of the corium. They very often give the skin a 
punctate appearance. They constitute irregularly shaped, 
roundish or serpiginous patches, without definite outline, 
varying in size from a pea to a walnut, or larger. Later, 
these patches not infrequently coalesce. 

The puncta, or subcutaneous points, referred to, increase 
in size and become more prominent, resulting in the forma- 
tion of papules, and ultimately tubercles (lupus tuberculo- 
sa). It is at this stage that the disease usually comes under 
notice. The papules are of all sizes, from a pin-head to a split 
pea, are dark red in color, and are covered with a thin layer 
of imperfectly-formed epidermis. They are quite solid and 
without pain. The patch now becomes more circumscribed 
and pronounced in outline. Having arrived at this period of 
development, the process may terminate either in absorp- 
tion of the lesions, leaving a desquamative, atrophic, partially 
cicatricial tissue (lupus exfoliativus); or, in disintegration 
and complete destruction of the infiltrated skin, resulting in 
ulceration and crusting (lupus exulcerans, lupus exedens). 
If exuberant granulations spring up about the ulcer, the con- 
dition is that known as lupus hypertrophicus. 

From the course of the disease as described, it will be 



422 NEW GROWTHS. 

Been that the different forms are but modified stages of one 
process. It may be arrested at any period of its evolution, 
and in this manner constitute a variety of the disease. Not 
infrequently several or all of the lesions may be present at 
the same time, giving rise to a multiform picture in which 
the whole course of the affection may be studied. 

Lupus in its early stages is unaccompanied by marked sub- 
jective symptoms, neither itching, burning, nor .pain being 
present in any degree worthy of special mention ; later, a 
certain amount of pain may be present. 

The disease has its seats of predilection ; it is commonly 
found about the face, especially the nose, cheeks, and ears. 
It also very frequently attacks the extremities, particularly 
the fingers, where it is followed by serious distortion and 
atrophy. The body may also be involved. It is an exceed- 
ingly destructive process, w T herever it occurs, occasioning 
extensive ulcers, ugly cicatrices, and at times great deformity. 
It does not confine its ravages to the skin, but occasionally in- 
vades other tissues, as the mucous membrane and cartilage. 
The mouth, cartilages of the nose, ear, larynx, and even the 
eye, may be the seat of lupus vulgaris. 

Etiology. — The causes are obscure. It is a disease usually 
originating in childhood ; it almost invariably makes its first 
appearance before puberty. Hebra and Kaposi state that it 
is never congenital. It is rarely, if ever, hereditary; it is 
well known that children with lupus are almost always found 
to be descended from parents who have not had the disease. 
It attacks both males and females in about like proportion. 
Lupus vulgaris is of very much more frequent occurrence in 
certain countries than in others. It is common in Ireland, 
Germany, and Austria, less so in England and France; on the 
other hand, it is decidedly rare in the United States. .The 
majority of cases encountered in this country occur among 
the poor Irish and German population. The general health 
of lupus patients is found to vary somewhat. At times they 
are broken down, debilitated, ill fed, and improperly cared 
for; other cases, however, show no signs of poor health. In 
certain instances, as reported by various observers, it is noted 
to occur in those affected with tuberculosis. 



LUPUS VULGARIS. 423 

It is not caused by syphilis. Lupus and syphilis have 
nothing in common beyond their tendency to destroy the tis- 
sues, a feature shared also by other diseases, as, for example, 
carcinoma and elephantiasis Grsecorum. Both the history and 
the course of these two diseases are quite opposite. Lupus 
and scrofuloderma must also be viewed as distinct processes, 
the former being frequently encountered in cases to which 
the term scrofnlosis would be altogether inapplicable. 

Pathology. — This subject has of late received careful study 
at the hands of Auspitz,* Neumann, Virchow, Kaposi, Fried- 
lander,! and others.J 

The results of microscopical investigation vary somewhat, 
as different lesions and stages of the disease are examined. 
The lupus process is one which, briefly stated, may be said 
to consist of a new cell-infiltration throughout the cutaneous 
tissues. It has its starting point in the corium itself, and 
when fully developed is made up of a number of aggrega- 
tions or clusters of cells, having their seat in and between the 
fibres of connective tissue, which appear either displaced or 
entirely obliterated. The cells when examined critically are 
seen to be unusually minute in size, to contain a distinct 
nucleus, and are notable for the peculiarity of remaining for a 
long period without undergoing change. In structure they 
are not unlike granulation cells. Friedlander, who has made 
recent researches, claims that they are tubercle, and conse- 
quently views lupus as a local tuberculosis. In the later 
stages of the disease fatty degeneration of the cells occurs. 
The process usually terminates in ulceration, followed by an 
atrophic cicatrix of a marked character. 

Diagnosis. — Lupus vulgaris is to be distinguished from 
syphilis, the disease with which it is most liable to be con- 
founded, by attention to the papules, tubercles, ulcers, crusts, 
history, and course of the affection, all of which are different 
in the two disorders. The ulcerative stages most closely re- 
semble each other. The ulcers of lupus are, in the majority 
of cases, comparatively superficial ; those of syphilis are or- 

* Die Zelleninfiltration der Lederhaut, Med. Jahrb., Wien, 1864. 

f Virchow's Archiv, vol. lx. 

X See a paper by the author in Phila. Med. Times, No. 142, 1874. 



424 NEW GROWTHS. 

dinarily quite deep, and have an excavated appearance. The 
individual ulcer of lupus is usually less extensive in area than 
that of syphilis. In lupus, moreover, there are, as a rule, 
a number of points of ulceration, which incline to become 
confluent; whereas in syphilis if several exist they usually 
remain separate and distinct. The border of the syphilitic 
ulcer is sharply defined ; that of lupus is not apt to be so. 
The secretion of syphilitic ulcers is always copious, and offen- 
sive in odor; in lupus the discharge is slight, and inoffensive. 
The crusts of lupus are usually scanty, and reddish brown in 
color ; those of syphilis are bulky, and frequently greenish. 
The histories of the two diseases are altogether unlike : lupus 
is very slow in its course; syphilis, comparatively, rapid. A 
fortnight or six weeks is often sufficient to produce the char- 
acteristic ulcer of syphilis ; months or years would in all 
probability be required to bring about the same amount of 
destruction in lupus. If the case be one of syphilis, other 
symptoms of this disease will almost always be found present. 
The cicatrices of lupus are always distorted, hard, shrunken, 
and yellowish ; in syphilis they are softish and whitish, and 
are not apt to be particularly disfiguring, considering the 
amount of ulceration which" has preceded. 

Lupus should not be confounded with epithelioma. The 
localization of epithelioma, its usually painful character, and 
its seat, together with the circumscribed induration of the 
lesion, will in most cases serve for its correct diagnosis. In 
the ulcerative stages, however, the diseases may often resem- 
ble each other. The destructive tendency of epithelioma is 
notable ; the loss of substance is seldom so great in lupus. 
The ulceration of epithelioma starts from a point and in- 
creases peripherally ; that of lupus begins usually at many 
points within the patch. The hard, everted border of epi- 
thelioma is never seen in lupus. The epitheliomatous ulcer 
is usually deep, with an uneven base ; that of lupus is more 
or less superficial, with a reddish base of fine granulations. 
The course of epithelioma is, as a rule, much more rapid 
than that of lupus. Epithelioma seldom, if ever, occurs in 
children ; lupus usually begins in childhood. 

The lupus patch can scarcely be confounded with eczema. 



LUPUS VULGARIS. 425 

The absence of all itching will alone suffice to distinguish it 
from this disease. Moreover, no scars accompany eczema. 
Here also the histories of the diseases are very different. 

Lupus erythematosus is never accompanied by ulceration ; 
this feature will always enable this disease to be diagnosed 
from lupus vulgaris. The patcbes in lupus erythematosus 
are superficial, uniformly reddish in color, hyperaamic, cov- 
ered with adherent, grayish scales, have a circumscribed, 
distinct margin, and are witbout papules or tubercles. The 
sebaceous glands and follicles are always markedly involved 
in lupus erythematosus; in lupus vulgaris they remain un- 
affected. The age at which these two diseases usually first 
appear is also to be remembered. 

Acne rosacea at times bears some resemblance to lupus 
vulgaris, but may readily be distinguished by its dilated ves- 
sels, redness, the presence of acne pustules, history, and 
course. 

Treatment. — Lupus vulgaris is one of tbe most chronic and 
obstinate of all cutaneous diseases, aud calls for both external 
and internal treatment. The disease seldom yields except 
under the most determined and vigorous measures. It is, 
however, decidedly more amenable to treatment, and espe- 
cially constitutional treatment, in this country than abroad. 
In Austria the disease defies constitutional remedies. The 
general condition of the patient is first of all to be carefully 
inquired into. The age, past history, mode of life, present 
state, as regards both the extent of the disease and health, 
and surroundings, must all receive attention. 

Hygienic influences are to be adopted, and to be insisted 
upon as very important towards a satisfactory result. Fresh 
air and abundance of out-door exercise are to be freely taken. 
The morning cold bath, followed by frictions, or, if better 
suited to the individual, the vapor bath, should be directed 
as may seem proper. The digestive tract should be kept in 
order, the bowels and other functions regulated, and every 
means employed to promote health. 

The diet is likewise of vast importance. It should consist 
of the most nutritious articles of food, including meat, eggs, 
milk, malt liquor, and whatever else may be well digested. 



426 NEW GROWTHS. 

Cod-liver oil is certainly one of the most valuable medici- 
nal remedies, and should be freely administered for a long 
period, care being taken, however, not to nauseate the patient. 
Should this occur, its use may be interrupted from time to 
time. Iodide of potassium is of almost equal value. In 
several cases I have found it to succeed admirably ; its in- 
fluence should always be tested before severe external reme- 
dies are resorted to. From five to ten grains three times 
daily may be ordered; if there be idiosyncrasy less may be 
given. It is best prescribed with some palatable syrup or 
elixir, well diluted with water. Iodine itself, in small doses, 
may often be advantageously employed, especially in combi- 
nation with cod-liver oil. Syrup of the iodide of iron, and 
other preparations of iron, are also useful. 

External remedies are quite as important as internal treat- 
ment. A large number of preparations, most of them of a 
caustic nature, have been recommended; they should be se- 
lected to suit the particular stage and variety of the disease, 
The amount of surface and the region of the body involved 
are also to be taken into consideration. In the earlier 
stages stimulating applications may be employed with a view 
to bring about absorption ; equal parts of tincture of iodine 
and glycerine, repeatedly painted over the part, mercurial 
plaster, tar, and ointment of the red iodide of mercury, 
may be used for this purpose. Strong caustics are, however, 
necessary in the great majority of cases that come under ob- 
servation. Of these, potassa, nitrate of silver, arsenic, car- 
bolic acid, acetate of zinc, red iodide of mercury, chloride of 
zinc, and lime, either alone or in various combinations, are 
the most valuable. 

Potassa may be used in those cases where a powerful effect 
is required; it should always be handled with extreme care, 
on account of its violent action upon the tissues. In stick 
form it may be applied to large tubercles and hypertrophic 
conditions which require destruction. A solution of potassa, 
one or two drachms to the ounce, is also at times of service, 
applied by means of a charpie brush. The operation is se- 
vere, although the pain does not continue long; it ceases 
usually upon neutralization of the alkali with an acid, which 



LUPUS VULGARIS. 427 

should invariably be applied immediately after the cauteriza- 
tion. For this purpose dilute acetic acid or vinegar will be 
found serviceable.* 

Nitrate of silver, both in stick form and in solution, equal 
parts with water, constitutes one of the best caustics; it may 
be employed without danger of leaving scars. It never pen- 
etrates deeplj 7 . Papules and tubercles may be disturbed by 
boring into them with the solid stick; patches are most suc- 
cessfully treated with the solution, repeatedly applied with the 
charpie brush. It is the mildest and safest of the caustics, 
and should therefore be employed about the region of the 
face, where cicatrization is to be guarded against as much as 
possible. Hebra prefers it to all other caustics. 

Arsenic has long been extensively used. It possesses the 
advantage that when applied to a part it only destroys the 
diseased tissue, leaving the healthy skin intact; on the other 
hand, it is a painful application. Cosme's paste, as modified 
by Ilebra, is the best method of employing it : 

R Acidi Arseniosi, ^i ; 

Hydrarg. Sulphuret. Hub., £i ; 

Ungt. Simplicis, Hji. , 
M.— Ft. ungt. 

This is to be spread, quite thick, on a piece of cloth, and 
applied closely to the patch for two or three consecutive 
days, until the lupus nodules and points are seen to be 
blackish and destroyed. The ointment is to be renewed 
each day, as long as it may be used. On the second and 
third days the pain is apt to be severe, requiring all the for- 
titude of the patient to bear it. The results from this paste, 
however, are at times very satisfactory. 

Carbolic acid has of late been repeatedly tried, but with 
indifferent success; it acts quite superficially and produces 
considerable pain. Acetate of zinc, well spoken of by Neli- 
gan, and more recently by Weisse,f may be applied in the 
form of the crystal. Its use should be repeated from week 

* For more extended remarks upon the use of potassa as a caustic, see Epi- 
thelioma. 

f Amer. Jour, of Syph. and Derm., Oct., 1870. 



428 NEW GROWTHS. 






to week until cicatrization takes place. The pain is said to 
be severe at the time, but not to continue; it may be re- 
lieved by the use of water. An ointment composed of equal 
parts of the red iodide of mercury and simple ointment, 
applied upon a piece of cloth, is used very frequently by 
Hardy ; it produces a caustic effect, with discharge, at the 
expiration of from six to twelve hours, followed by a crust, 
which falls oft* in a week or ten days, leaving a healthier con- 
dition of the skin. 

Chloride of zinc may be used as a paste, as in the following 
formula, proposed by Hebra: Equal parts of chloride of zinc 
and chloride of antimony, with sufficient strong hydrochloric 
acid to dissolve the chloride of zinc, are rubbed up in a mor- 
tar with enough powdered liquorice root to make a paste. 
It should be spread upon a piece of cloth and applied at once, 
w T hile still moist. It should be permitted to remain on for 
eighteen or twenty-four hours, when an eschar will have been 
formed. It is a very strong caustic, and should only be ap- 
plied when it is desirable to destroy the whole patch, for it 
acts upon healthy as well as upon diseased skin. 

The Vieuna paste may be recommended for a similar pur- 
pose. It consists of equal parts of potassa and lime. This 
is to be made into a paste with alcohol at the time it is 
required for use, and applied upon a cloth for live or ten 
minutes only ; it destroys everything with which it comes 
into contact, producing a blackish eschar. The action of 
the caustic should be stopped with acetic acid and water, 
after which the surface may be dressed with a water com- 
press or with simple ointment. When either of the two 
latter preparations is employed, the skin surrounding the 
patch should be carefully protected with strips of piaster or 
linen. 

The galvano-caustic has been used with success by Hebra; 
variously-shaped wires and other forms of apparatus are re- 
quired to meet the different varieties of the disease. The 
actual cautery may be used with similar result. Yolkmann 
has devised a method of treating lupus by means of a small, 
round or oval, metallic scoop with sharp edges. The lupus 
infiltrations are scraped or dug out with the instrument, after 



SCROFULODERMA. 429 

which, in order to secure complete destruction of the disease, 
the skin is subjected to punctiform scarification with a pecu- 
liar small-bladed knife. The process is painful, and requires 
to be repeated at intervals.* The results are said to be 
satisfactory. 

Prognosis. — This will depend upon the form of the dis- 
ease, its duration, the age of the patient, and the extent of 
surface involved. The disease runs an exceedingly chronic 
course. Even in favorable cases energetic and continued 
treatment is necessary to bring about a satisfactory result. 
If the disease be confined to one patch or region, a more 
favorable termination may be anticipated. Relapses very 
frequently occur. The thoroughness of the external treat- 
ment must also influence the prognosis. The deformity 
attending and following the disease is usually great ; ugly, 
hard scars, and contractions of the joints, are apt to remain. 

SCROFULODERMA. 

Symptoms. — Under the name scrofuloderma I would include 
those morbid conditions of the skin which exist as an expres- 
sion of the peculiar state of the system designated scrofula, 
scrofulosis or struma. The cutaneous lesions vary, but are 
nevertheless characterized by certain features which serve 
to distinguish them from other diseases. As a rule, the 
affection begins in one or more of the lymph glands, which 
become swollen and permanently enlarged, constituting 
hard, roundish or oval tumors, unattended in the commence- 
ment by redness or pain. They increase in size very slowly. 
Having attained certain dimensions, as, for example, the size 
of an almond, they may either remain in this state, or, as is 
usually the case, undergo softening. The skin covering them 
becomes hypersemic, and by degrees thin and sensitive. The 
color is peculiar ; it is usually of a light or dark purplish or 
violaceous hue. 

In the course of time, ordinarily months, fluctuation is ex- 

* For a full description see his paper, Sammlung klinischer Vortrage, No. 
13. Leipzig, 1870. See also abstract of a paper by Dr. Ernst Yeiel, Amer. 
Jour, of Syph. and Derm., vol. v. p. 96. 



430 NEW GROWTHS. 

perienced, and the tumor breaks open at one or more points 
and gives forth a more or less copious discharge, composed 
of pus, blood, serum, and a whitish or yellowish, flaky, 
caseous matter. The character of the fluid varies; at times 
it is puriform, in other cases thin and watery. The dis- 
charge does not usually cease suddenly, but continues oozing 
in greater or less quantity for an indefinite period. Sinuses 
are apt to form, which not rarely burrow deeply and invade 
the adjacent tissues. The condition is now chronic, and may 
remain, becoming better and worse from time to time, for 
months or years. 

Sooner or later, however, the glands break down com- 
pletely, terminating in ulcers. The tendency of the disease 
is to ulceration. The ulcers vary exceedingly as to their 
size, shape, depth, and general features, according to their 
seat and other circumstances. They have no definite shape, 
although they are usually elongated or almond-shaped. Their 
edges are irregular and ill defined, differing in this respect 
from those of syphilis, which are sharply cut and well de- 
fined; they are, moreover, ordinarily thin, covered with a 
scanty, watery secretion, more or less undermined, and have 
a pale-red or a bluish color. The base of the ulcer is uneven, 
and is usually studded with unhealthy-looking, pale, flabby 
granulations, which are covered with a grayish, flaky deposit. 
The ulcer inclines to bleed easily. According to the amount 
of secretion and its nature, will the crusting be slight or ex- 
tensive; as a rule, it is inconsiderable. The crust may be 
either brownish or blackish, or pale and grayish in color; it 
is usually thin and adherent; when removed the surface of 
the ulcer is apt to bleed. The scrofulous ulcer manifests no 
disposition to heal; its course is always chronic. Not infre- 
quently it will remain in about the same state, alternately 
better and worse, for mouths or years. As a rule, it is not 
painful. 

The reparative process is always slow. The scar which 
eventually succeeds the ulcer is generally of a hard, irregu- 
larly contracted, knotty character. Compared with other 
scars, it is an ugly formation, usually occasioning contraction 
of the surrounding integument. 



SCROFULODERMA. 431 

Scrofuloderma manifests itself upon various regions. It 
is most often met with about the face, beneath the lower jaw 
and around the neck, and in the axillas and groins. It is also 
encountered about the thorax, and on the hands and feet. 

A variety of concomitant symptoms, indicative of the 
scrofulous state, usually accompany scrofuloderma. Chronic 
inflammatory affections of the eyes, discharges from the ears, 
and coryza are at times present, particularly in children. 
In other cases, swellings of the joints and enlargement of 
the bones are observed. The glands in various parts of the 
body are apt to become enlarged, constituting indolent sub- 
cutaneous tumors. The skin very often has a pale, yellow- 
ish appearance, and is soft and flabby; the face is at times 
puffed. Old scars, the result of previous disease, may also 
usually be detected in one or another region. 

Etiology. — Scrofuloderma may be inherited or it may be 
acquired. It is usually inherited. It very frequently arises 
from the marriage of blood relations. The causes which are 
recognized as being capable of producing the disease during 
life, are insufficient and unwholesome food, depressing exter- 
nal influences of all kinds, as, for example, long residence in 
cold and wet climates, impure air, damp and dark dwellings, 
want of exercise, and the like. It is also known to follow 
certain diseases, as, for example, measles and scarlatina, and 
remotely, in the third or fourth generation, syphilis. It is 
apt to show itself first in early childhood. It is more com- 
mon in the colored than in the white race, and is particularly 
prone to attack mulattoes. It is not contagious. 

Pathology. — The cause of scrofuloderma is to be found in 
the peculiar state of the system which has been termed scrof- 
ulosis, the nature of which is still involved in obscurity. 
Recent views of certain pathologists (Rindfleisch, Waguer, 
Green, and others) consider it to be identical with tuber- 
culosis; clinically, however, scrofulosis and tuberculosis are 
different diseases. 

Diagnosis.— It is to be distinguished from lupus vulgaris 
and from syphilis by the presence of the concomitant general 
symptoms of scrofula, and by the peculiar features of the 
lesions, which differ materially from those of lupus vulgaris 



432 NEW GROWTHS. 

and syphilis. The characters of the primary lesions, the 
ulcers, the crusts, and the course of these three diseases are 
very different. 

Treatment. — The treatment of scrofuloderma must be di- 
rected against the general disease. The internal remedies 
of service are the preparations of iron and iodine, phos- 
phorus, lime, and cod-liver oil. The last named is by far 
the most valuable remedy. These may be given alone or 
combined. Fresh air, especially the sea air, and proper ex- 
ercise are of the greatest importance. The diet should be 
generous, and should consist largely of animal food. Locally, 
the ulcers are to be treated by stimulating ointments, the 
various mercurial preparations being the most reliable. 

ELEPHANTIASIS GRJECORUM. 

Syn. Lepra; Lepra Arabum ; Leontiasis ; Satyriasis; Leprosy; Germ., 
Der Aussatz ; Fr., La Lepre; Norwegian, Spedalskhed. 

Elephantiasis Gilecorum is an endemic, chronic, malignant, 
constitutional disease, characterized by alterations in the 
cutaneous, nerve, and bone structures, resulting in anaes- 
thesia, ulceration, necrosis, general atrophy, and deformity. 

Symptoms. — The disease is a constitutional one, and in- 
volves the whole organism most profoundly. It exhibits its 
presence by both general and local symptoms of a marked 
character. Its invasion is usually slow and insidious, years 
often elapsing before it becomes pronounced. 

Premonitory symptoms, consisting of malaise, mental de- 
pression, languor, sleepiness, loss of appetite, nausea, chills, 
repeated attacks of fever, general debility, nervous prostra- 
tion, and pains in the bones, are mentioned as being present 
in the majority of cases. These may be severe in their 
intensity, or, on the other hand, quite slight, and may con- 
tinue for weeks, months, or years without other symptoms. 
Sooner or later, however, more characteristic features mani- 
fest themselves, prominent among which are the lesions of 
the skin. These, like the earlier symptoms, vary in form; 
they may be either bullous, macular, pigmentary, or tuber- 
cular in nature. They may appear separately, following one 
another in succession, or, as not infrequently happens, several 



ELEPHANTIASIS GR.ECORUM. 433 

or all of them may be present at the same time. The cuta- 
neous manifestations, like those of syphilis, are remarkable 
for their multiformity.* They also vary exceedingly as re- 
gards the degree of their development; at times they appear 
to constitute the principal symptoms of the disease, while in 
other cases they seem altogether subordinate to the lesions 
of other tissues. Various organs of the body are, sooner or 
later, influenced by the disease, as, for example, the nerves. 
It will thus be seen that the skin trouble represents but a 
portion of a serious and even malignant systemic disorder. 

Two forms of leprosy are recognized, the tubercular and 
the anaesthetic. It is necessary to state, however, that no 
absolute line separates the one variety from the other. Al- 
though the symptoms of each are quite distinct and well 
marked, they not infrequently appear simultaneously upon 
different parts of the body. One variety may, moreover, 
pass into the other. From these remarks it will be under- 
stood that the manifestations of either form of the disease 
are liable to vary considerably. 

Elephantiasis Gr^corum Tuberculosa — Tubercular 
Leprosy. — As the name indicates, this variety is attended 
chiefly by the formation of masses of infiltration and tuber- 
cles ; together with these, however, are found other lesions, 
at times almost as prominent in character as the tubercles. 
An eruption of bullae, very similar to those observed in 
pemphigus, usually constitutes one of the first cutaneous 
manifestations. These may show themselves in an irregular 
manner for some time before other more definite symptoms 
appear; it is said that they more frequently precede the 
anaesthetic than the tubercular form of the disease. Maculae 
now make their appearance as distinct, smooth, shining, 
erythematous patches. The outlines of these spots are for 
the most part defined, the patches themselves consisting of 
circumscribed areas of infiltration into the skin ; in other 
cases they are not surrounded by any line of demarcation, but 



* I was particularly impressed with this characteristic of the disease in 
examining the patients of the Leper Hospital at Granada, Spain, during a 
visit to this institution. 

28 



434 NEW GROWTHS. 

seem to fade into the healthy tissues. The patches have a 
smooth surface and are usually upon a level with the skin ; 
they may be somewhat raised. In color they are yellowish 
or reddish, assuming usually a dusky yellowish or brownish 
hue as they grow older. Not rarely they are pale yellow in 
color, and have the appearance of a solid, fatty, lardaceous 
deposit beneath the epidermis. These spots are very aptly 
likened to a piece of cut, raw bacon, inserted in the skin. 
They are commonly surrounded by a delicate pinkish or 
lilac border, which upon close inspection is seen to be made 
up of a minute plexus of bloodvessels. 

The sensibility of these patches is materially altered from 
the first, and is found to vary between hyperesthesia and 
complete anaesthesia; at first they are usually hyperaesthetic, 
while later they become markedly anaesthetic. 

They may appear upon any part of the body, although 
their most common seat is upon the trunk and extensor 
surfaces of the extremities; not rarely they are present in 
such numbers as to involve a considerable surface of the 
body. Their course is variable; they may disappear and re- 
appear from time to time, or they may remain as permanent 
lesions, in which case they increase in size. 

Sooner or later the disease manifests itself in the form of 
variously shaped and sized nodules and tubercles; they may 
assume the definite outline of tubercles, or they may develop 
into irregularly-shaped prominences and elevated masses. 
When typical they are roundish in form and of all sizes 
from a pea to a cherry or even a walnut. They may either 
stand forth conspicuously from the surface, or on the other 
hand be but slightly raised. 

They have a yellowish or brownish color; very frequently 
they have a bronzed aspect. In consistence they are quite 
firm. Their seat is in the skin and subcutaneous tissues. 
They are more or less painful when pressed upon. They 
manifest themselves upon all regions of the body, but gen- 
erally form in greatest numbers about the face. The fore- 
head, eyebrows, cheeks, nose, lips, chin, and ears, are the 
localities where they usually develop, causing at times entire 
obliteration of the natural lines of the region. The other 



ELEPHANTIASIS GILECORUM. 435 

portions of the body, notably the trunk, buttocks, arras and 
legs, lingers and toes, are likewise very often invaded. 

The deformity which the presence of the tubercular masses 
occasions is very striking. When they occur about the face, 
the features become horribly distorted. The tissues appear 
more or less swollen and infiltrated ; the skin is here and 
there thickened, puffed out, and moulded into unsightly 
shapes. The natural lines of the surface are greatly exag- 
gerated, and give a bold, ferocious expression to the face. 
The skin of the forehead and eyebrows is usually markedly 
thickened and corrugated, and stands out in bold promi- 
nences, which suggest a likeness to the head of the lion 
(leontiasis). The nose, cheeks, and mouth are also the seat 
of extensive infiltrations. The disfigurement is generally 
very great. The rest of the body, especially the hands, feet, 
fingers and toes, is in like manner made ugly by the disease. 

Later in the course of the disease the tubercles appear 
upon the mucous membrane of the mouth, extending into the 
various passages, attacking the pharynx, epiglottis, larynx, 
and mires. The eye also suffers. 

The course of the tubercle varies. It may last for a long 
period without undergoing much change, or, on the other 
hand, it may at once pass into softening and ulceration; 
or it may disappear by absorption. Ulceration occurs for 
the most part about the fingers and toes, the ulcers being 
covered with adherent, brownish crusts. 

Elephantiasis Grecorum Anesthetica — Anesthetic 
Leprosy. — This variety may appear either in conjunction 
with the tubercular form of the disease, or alone, in which 
case it is characterized by the presence of a number of 
symptoms in addition to the anaesthesia. 

Frequently one of the first symptoms encountered is an 
eruption of bullae, which appear in an irregular manner, 
coming out from time to time, followed by a slight scar and 
pigmentation. They may continue to show themselves for 
an indefinite period, after which signs of anaesthesia are 
noticed about the seats of former bullae. In other cases the 
maculae referred to in describing the tubercular form con- 
stitute the earliest symptom. Hyperesthesia of the skin is 



436 NEW GROWTHS. 

also one of the early signs of the disease, the patient com- 
plaining of pains and burning sensations. This symptom is 
usually succeeded by anaesthesia, affecting either a limited 
portion or the greater part of the surface. The macular 
patches are noticed to be anaesthetic, often to such an extent 
that a pin may be thrust into and through them without 
causing pain. Later, portions of the skin free of maculae 
become in like manner anaesthetic. The skin now begins to 
assume an atrophic condition ; it is dry, yellowish or brown- 
ish in color, and more or less wrinkled. 

Following this alteration in the structure of the skin, the 
subcutaneous tissues and muscles undergo atrophy, giving 
rise to deformity, distortion, and joint trouble, especially of 
the fingers and toes. The hair and nails also undergo the 
same change, and are either greatly altered in their structure 
or are completely cast off. The hands and feet suffer most 
seriously, and are subject to great mutilation. The fingers 
and toes become bent, crooked, and contracted. Sooner or 
later the bones of these parts are attacked, causing destruc- 
tion of the joints and of the bones themselves. The skin 
over the joints becomes excoriated and ulcerated, the ends of 
the bones undergo disintegration, and the phalanges finally 
either become absorbed or drop off. Not only fingers and 
toes but also hands and feet may gradually be lost. The 
tissues of the extremities are now more or less completely 
anaesthetic, and are wasted at times to half their former size. 

Etiology. — The causes of this disease, notwithstanding the 
great effort that has of late been made to elucidate them, 
still remain obscure. A multitude of facts, however, of 
extreme interest have been brought together, from which 
valuable information has been deduced. Leprosy has ex- 
isted from time immemorial, quite accurate descriptions of 
it being found in the writings of the ancients ; frequent 
reference to it is also made in various portions of the Bible. 
At the present time the disease, existing as an endemic 
disease, is limited to certain geographical districts, which, 
however, embrace an extensive tract of territory, as may be 
seen by the following enumeration of the countries. 

It exists in Africa, along the shores of the Mediterranean, 



ELEPHANTIASIS GE.ECORUM. 437 

Atlantic and Iudian Oceans, as well as in the interior of the 
country; also in Asia Minor, Arabia, Persia, India, China, 
Japan, Kamtschatka, the various islands of the Pacific 
Ocean, and Australia. In Europe, it is found in Norway, 
Southern Spain, Greece, and Southern Eussia. Upon the 
western hemisphere it occurs in Mexico, Central America, 
in the islands of the West Indies, along the coast of South 
America, and especially in Brazil. It also exists to some 
extent in the island of Iceland. Cases originating in one or 
another of the above countries are occasionally encountered 
in the United States.* It is said that cases occur here and 
there endemically in our country. Further observation, how- 
ever, is needed to corroborate this statement. 

Thus it will be seen that its distribution is very extensive. 
It is, of course, very much more common in certain localities 
than in others, notably so in Southern Asia and in the islands 
of the Pacific Ocean. The disease seems to be caused by 
different influences as it occurs in one country or in another; 
it therefore becomes difficult to determine upon any one 
cause; certain points, however, are well determined. 

It is in very many instances hereditary, and may be handed 
down, from parent to child, through a long series of genera- 
tions. The disease is, in all probability, not contagious. It 
cannot be contracted, it is said, by contact. A leper and a 
healthy person may live together as man and wife through 
life without the latter contracting the disease. 

The most potent causes in the production of the disease 
appear to be intimately connected with climate, state of the 
soil, food, and habits of the people. Investigations concern- 
ing the nature of the climate in those countries in which the 
disease exists, point to no conclusions which throw any light 
upon the subject. From the geographical distribution just 
alluded to, it will be seen that though more common in trop- 
ical climates it also occurs in the coldest of climates, as, for 

* At Tracadie, in the province of New Brunswick, there has long existed 
a small colony of lepers (in 1863 they numbered twenty-three persons). They 
are French Roman Catholics, and are said to be of the lowest class. The 
disease was probably introduced into the country by a French emigrant 
family from St. Malo, Normandy, in the early part of the present century. 



438 NEW GROWTHS. 

example, Iceland and Norway. The state of the soil has 
been regarded by many as having a potent influence in the 
production of the disease, it being believed that a peculiar 
"malaria" is given off in the districts in which leprosy occurs. 
A glance at the country will show that it is for the most 
part low, marshy, malarious, bordering on the sea-coast or 
surrounded by water. 

The majority of those attacked by the malady are in the 
lowest walks of life, surrounded by abject poverty and des- 
titution, fit subjects for disease of any kind. On the other 
hand, the disorder also attacks those in the most favored 
circumstances. The food used by the inhabitants in many 
of the leprosy districts is of a very inferior quality, consist- 
ing in great part of fish, oil, rice, and other articles of food 
peculiar to the country, and upon which the natives live 
almost exclusively. 

The disease occurs in both sexes, and may show itself at 
any period of life from childhood to old age. It has no con- 
nection with syphilis. 

Pathology. — The anatomy of leprosy has been carefully 
studied by Danielssen and Boeck,* Virchow,f Xeumann,J 
Kaposi, § Carter,T and others, with very similar results. 

The disease consists in a deposit of new material, made up 
of cells similar to those encountered in lupus and syphilis. 
The patches of infiltration and tubercles have been examined 
in all stages of development; their structure differs some- 
what as they are recent or old formations. When cut into, 
well-formed tubercles present a firm, yellowish or reddish, 
finely granular surface. The mass has its seat mainly in 
the corium, but very often extends down into the subcuta- 
neous connective tissue. As a rule, it is not circumscribed, 
but inclines to spread out in various directions in the form 



* Traite de la Spedalskhed, avec un Atlas de 24 planches coloriees. Paris, 
1848. 

f Loc. cit., Bd. ii. p. 512. 

+ Loc. cit., p. 362. 

$ Loc. cit., vol. iv. p. 172. 

^ Transactions of the Med. and Phys. Soc. of Bombay, 1862, New Ser., 
vol. viii. ; Trans. London Path. Society, vols. xiii. and xiv. 



ELEPHANTIASIS GR.ECORUM. 439 

of a diffused infiltration or as irregular processes. Under 
the microscope the deposit is seen to consist of a delicate 
network, containing numerous, small, round, nucleated 
cells, closely packed together. According to Kaposi, in the 
younger tubercles the cellular infiltration is not uniform, but 
consists of small foci, which are most numerous around the 
thick-walled bloodvessels, glands, and hair follicles. The 
intermediate connective tissue only contains isolated cellular 
deposits. The older the tubercles or patches of infiltration, 
the more numerous, uniformly and densely crowded, do the 
cells become, the intercellular substance finally almost com- 
pletely disappearing. As the process advances, the epider- 
mis, hair, sebaceous and sweat glands all atrophy, and in 
time become more or less obliterated. Ultimately the tuber- 
cles incline to soften, disintegrate, and break open into 
chronic, superficial or deep, discharging ulcers f the course 
of these formations may be compared to that of the gum- 
matous syphiloderm, although more sluggish. 

The nerves of the body undergo marked and peculiar 
changes. They have been very fully described by Virchow.* 
The long nerves, as the ulnar or median, are, as a rule, 
swollen here and there along their course. The color of the 
nerve is apt to be altered; in place of the normal white color 
it is usually grayish, or of a smoky tint. The nerve is also 
generally firmer than normal, or it may even be hard. A 
transverse section under the microscope shows the structure 
to be more homogeneous than in health. The external nerve 
sheath is but little altered. The neurilemma is usually more 
or less changed ; at times it is hardened. The most impor- 
tant lesions, however, are observed in the septa within the 
nerve fasciculi, and in the interstitial substance, between the 
nerve fibres, and consist of a deposition in these localities of 
a highly refractive material. With a high power this material 
is found to be a mass of densely packed cells. These changes 
bavins: their seat about the nerves account for the clinical 
symptoms of hyperesthesia and anaesthesia, which are always 
so conspicuous in the course of the disease. 

* Loc. cit., Bd. ii. pp. 522, 523. 



440 NEW GROWTHS. 

Diagnosis. — In countries where the disease is endemic, even 
the premonitory symptoms would be regarded with some 
suspicion, while the appearance of the cutaneous eruption 
would leave no room for doubt; but not so in districts in 
which the disease occurs only in isolated cases, or in those 
countries where it is altogether foreign, and to which it has 
been imported; in these instances it is liable to be mistaken 
for other disorders. The symptoms of leprosy, however, 
taken as a whole, are of so marked a character that if they 
be borne in mind it will be almost impossible to confound 
them with those of other diseases. 

The macular and tubercular varieties are liable to be mis- 
taken for syphilis.* The eruption of leprosy, in its early 
stages, is not unlike that of the macular and papular syphi- 
loderms. It will be found to differ from syphilis, however, in 
the lesions being larger, and also more irregular in both size 
and distribution. The erythematous patches of leprosy are 
very often as large as the hand, and show signs of firm in- 
filtration throughout the skin. The pigmentation and color- 
ation of these patches are peculiar; they are more or less 
yellowish or brownish, and have a smooth, glazed appear- 
ance. The tubercles assume various sizes and forms ; they are 
for the most part much larger than those of syphilis, being 
not infrequently the size of hazelnuts or walnuts. In form 
they are apt to be irregularly shaped, and unevenly raised 
above the surface. In color they are darker than those of 
syphilis. The course which they run will be noted to be very 
different from that of syphilis; it is usually much slower than 
syphilis. 

The general expression of a face (the usual seat for this 
form of the disease) affected with tubercular leprosy is pecu- 
liar; the tissues are all more or less infiltrated with the new 
growth, and give a swollen, ugly, leonine appearance to the 
features, which is never seen in syphilis. 

* A case of leprosy resembling syphilis, occurring in a Cuban gentleman, 
came under my observation (through the courtesy of Dr. Beecher) in this 
city a few years ago. The disease had been seen by a number of physicians, 
who viewed it as an ulcerating tubercular syphiloderm. For the report of 
this case, see Photographic Eeview of Med. and Surg., vol. i. p. 72. 



ELEPHANTIASIS GR^CORUM. 441 

Later in the course of the disease the tubercles and infil- 
trated patches break down, and become superficial or deep 
ulcers, covered with adherent, blackish crusts, as a rule less 
bulky than those seen in syphilis. With ulceration come 
other characteristic symptoms of the disease, as anaesthesia, 
distortion of the hands and feet, absorption of bone tissue, 
atrophy, and other symptoms denoting profound constitu- 
tional infection. 

The yellowish, roundish patches of macular leprosy should 
not be confounded with vitiligo, a simple pigmentary affection. 
The two diseases may always be distinguished without diffi- 
culty by bearing in mind that in vitiligo the health is gen- 
erally good, and that the patch of disease is seen to consist 
of simple absence of pigment with a border of an increased 
amount of coloring matter ; the skin is seen to be normal in 
texture and sensibility, and to be smooth, the pigment change 
being the only sign of disease. The maculae of leprosy, on the 
other hand, consist of infiltrated skin having the form of a dis- 
tinct deposit of lardaceous looking substance, which is firm 
to the touch and either markedly hypereesthetic or anaesthetic. 

The whitish or yellowish patches of macular leprosy are 
also to be distinguished from the disease morphcea, an affec- 
tion of an entirely different nature.* Morphcea is an affec- 
tion of an atrophic nature, unattended by symptoms of con- 
stitutional disorder, the general health usually being good. 
The patches of morphcea differ from those of leprosy in 
being normal in sensibility, as well as in their course, which 
is one usually tending to spontaneous recovery. 

Treatment. — This has proved extremely unsatisfactory. The 
many remedies which have from time to time been employed 
against the disease with the hope of success need not be 
enumerated; suffice it to say that they all have proved power- 
less, notwithstanding their vaunted virtues. 

* I have adopted the term morphcea to represent the condition described 
upon p. 387, the opinion being held that there is no connection whatsoever 
between the anaesthetic patches of macular leprosy and the atrophic disease 
designated by modern dermatologists as morphoea. Contrary to the nomen- 
clature employed by Erasmus Wilson and Kaposi, the term morphoea is not 
applied by the author to any manifestation of leprosy. 



442 NEW GROWTHS. 

The general plan of treatment from which the greatest 
benefit has been derived is that which looks to the improve- 
ment of the condition of the whole health. The treatment 
should be constitutional and local. Change of climate and 
of residence is the first point to be attended to, and is of 
vital importance. The individual should at once seek a new 
home in some land free of the disease, preferably a moun- 
tainous district. Strict hygienic rules should be adopted, 
including exercise and frequent bathing. The subject of the 
nutrition of the body should also receive the most careful 
attention. The diet should be of the most nourishing quality, 
including meat and all those articles calculated to improve 
the general tone of the system. Tonics, especially iron and 
quinine, should be prescribed and taken for some time, either 
continuously or interruptedly. Iodide of potassium, iodine, 
and cod-liver oil are also to be administered with a view to 
producing an alterative effect. Mercury has been found to 
exert no beneficial influence upon the disease. Symptoms 
are to be treated as they may arise. 

The local treatment is also very important. Baths of 
various kinds are said to be of service ; they may be either 
simple, or medicated, as with iodine or sulphur. A number 
of remedies are used for the purpose of relieving the lesions 
of the skin, most of which tend to promote absorption of the 
infiltration. They are employed chiefly in the form of oils 
or ointments. The oil of the cashew nut, and Gurjun oil, 
in the form of inunctions, have of late been highly recom- 
mended. The former has beeu used extensively by Dr. 
Beauperthuy with a certain amount of success. It is rubbed 
upon the tubercles and anaesthetic patches of skin with a 
cloth or sponge, the operation being repeated once a week 
or as often as the skin will tolerate it. Carbolic acid, arsenic, 
and a host of other remedies have all been used with vary- 
ing result.* Electricity has been employed with a certain 
amount of success. 



* For a list of the remedies employed, as well as for a large amount of 
interesting material relating to the disease, see the Leprosy Keport of the 
College of Physicians. London, 1867. 



FRAMB(ESIA. 443 

Prognosis. — This is extremely unfavorable, for it is only in 
those cases in which the patient is able to devote every effort 
to the treatment of his disease that improvement is to be 
expected, and even in many of these cases the result is most 
unsatisfactory. The sooner the disease is recognized and 
placed under treatment the greater the hope of relief; after 
it has become disseminated throughout the tissues, the prog- 
nosis is most dire. 

Frambgesia, called also yaws, pian, and endemic verru- 
gas, is an endemic disease, characterized by marked and 
peculiar cutaneous symptoms, occurring in the West Indies, 
particularly Jamaica and Dominica, in the various countries 
of South America, and in Africa. The affection has received 
careful stud}' recently at the hands of Drs. Milroy* and 
Imray, of Dominica; Dr. Bowerbank,f of Jamaica; and 
Mr. Jonathan Hutchinson, J of London, to whose writings I 
am indebted for the following brief account. The eruption 
consists of variously sized reddish papules, tubercles and 
tumors, which are usually present in all stages of develop- 
ment. They begin as pin-head sized, hard, red points; later 
they reach the size of split peas, and resemble in appearance 
red currants or small raspberries. As they grow larger they 
incline to become fiat on their tops, and to be studded with 
yellowish points. In time they enlarge to the size of cherries, 
become softer in consistence, and are apt to break down and 
to ulcerate, discharging a thin, fetid, yellowish fluid. The 
lesions, although usually roundish and semiglobular, may be 
of any shape; at times the tubercles, in close proximity to 
one another, coalesce, forming patches of disease of a vege- 
tating; or funsroid nature. 

The appearance of the eruption varies with the stage of 
the disease; and with the color of the patient, whether black 
or white. In color the papules and tubercles are at first 

* Eeport on Leprosy and Yaws in the West Indies, by Gavin Milroy, M.D. 
London, 1873. 

f Quoted in Dr. Tilbury Fox's work on Diseases of the Skin. 

% Catalogue of the New Sydenham Society's Atlas of Skin Diseases, Part 
II. p. 145. See also Plate XLI. 



444 NEW GROWTHS. 

reddish or brownish ; according to Dr. Imray, " if yaws are 
observed as they first make their appearance on the surface, 
one or more minute whitish or yellowish points or spots will 
be perceived, not larger than a pin's head. These yellow 
spots are seen very distinctly on the dark skin of the negro. 
Gradually the spots enlarge, and begin to project from their 
surface, retaining for the most part their circular form, and 
have much the appearance of small globules of yellow pus." 
The same writer compares the typical tubercle to a " piece of 
coarse cotton wick, a quarter of an inch, more or less, in diam- 
eter, dipped in a dirty yellow fluid, and stuck on the skin in 
a dirty, scabby, brownish setting, and projecting to a greater 
or less extent/' which, although not so elegant a comparison 
as that of the strawberry, he believes to be more exact. Mr. 
Hutchinson, who reports a case occurring in an Englishman, 
compares the appearance of the lesions to red currants, with 
flat tops, of a bright pink color, glassy, and semi-transparent, 
but possessing the consistence of a raspberry rather than that 
of a currant. Larger formations, he adds, look not unlike 
small cherries. The surface of the tubercles varies ; it may 
be smooth or slightly scaly; or, on the other hand, it may 
be in a state of ulceration, covered with a thiii yellowish 
fluid, and crusts. 

The eruption generally manifests itself on the face, the 
upper and lower extremities, and about the genitalia ; the 
largest growths are said to occur on the lips, eyelids, toes, 
and genital organs. The lesions show no regularity of dis- 
tribution. The course of the disease is variable ; it may 
continue for months, or, if neglected, for years. There are 
no constitutional symptoms at first; later, the general health 
suffers. The tubercles are neither painful nor itchy. 

The disease is considered to be contagious, but not infec- 
tious; it is probably not hereditary. It has no relation to 
syphilis. 

The treatment, according to Dr. Imray, " is as simple 
as it is usually effective." It consists of attention to clean- 
liness, hygiene, good food, and the judicious use of mer- 
cury in conjunction with tonics. Iodide of potassium is 
also employed. The tubercles are best treated with a car- 



PELLAGRA. 445 

bolic acid solution or with a weak nitrate of mercury 
ointment. 

Pellagra is an endemic, constitutional disease, character- 
ized by a chronic inflammation of the skin, of an erythem- 
atous nature, accompanied usually with derangement of the 
digestive tract and with cerebro-spinal symptoms. The dis- 
ease may or may not be preceded by premonitory general 
symptoms. The eruption is confined to those parts which 
are commonly exposed to the sun, as the backs of the hands 
and feet, arms, legs, chest, and neck. The skin becomes 
red, and is the seat of violent burning sensations, which are 
greatly aggravated by exposure to the sun. The inflamma- 
tion may be superficial or deep-seated ; at times it is bright 
red, in other cases it is brownish-red. Later the* epidermis 
begins to desquamate, leaving a reddish, shining surface. 
Fissures are apt to occur. According to Rayer,* the inflam- 
mation may be intense, the epidermis rising into vesicles 
or large, irregularly-shaped bullae, succeeded by crusts. In 
other cases, the epidermis becomes thickened, hard and dry, 
yellowish or brownish in color, without having been pre- 
ceded by redness or burning. The symptoms are at their 
height during the summer, subsiding with the advent of 
winter ; they return, however, the following year, and usually 
in an aggravated form. Marked disturbance of the health is 
apt to occur with the cutaneous trouble, consisting of loss of 
appetite, thirst, nausea, indigestion, pains in the abdomen, 
with diarrhoea or constipation; these symptoms vary consider- 
ably. The patient becomes debilitated, is weak and feverish, 
and loses weight. In addition, nervous symptoms, character- 
ized by vertigo, pains in the head and spinal cord, delirium, 
convulsions, loss of memory, loss of muscular power, and 
depression of spirits, varying in intensity, often follow. 

The course of the disease is variable; it may continue 
several years, or, on the other hand, indefinitely. It is 
amenable to treatment in the majority of cases. Among 
the poorest class, it very frequently proves fatal. 

*Loc. cit., p. 1162. 



446 NEW GROWTHS. 

It is endemic in certain districts of Italy, especially Lom- 
bardy and Tuscany; it is also met with in the South of 
France. It occurs chiefly among the poorer population, 
notably those pursuing agricultural occupations. It attacks 
both sexes, and manifests itself at all ages. The cause of 
the disease has long been the subject of much discussion, 
although it is now generally conceded that it is produced 
by the use of diseased (ergoted) maize, which the inhabit- 
ants of the pellagrous districts consume in large quantities 
as an article of food.* Pellagra has also been attributed to 
malaria, bad hygiene, extreme poverty, bad water, and like 
causes, all of which are usually found to exist where the 
disease is endemic. The sun is the exciting cause. 

The treatment is directed against the general condition. 

SYPHILODERMA. 

Syn. Syphilis Cutanea ; Dermatosyphilis ; Syphilis of the Skin. 

Under this term are included the various manifestations 
of syphilis upon the skin. The syphilodermata, or " syphi- 
lides," as they are also termed, are numerous and constitute 
an important group of symptoms. They occur in a variety 
of forms, presenting themselves, in fact, in all the different 
lesions common to other cutaneous affections. They may 
occur at any period in the course of the disease, giving rise 
either to but slight inconvenience, or, on the other hand, to 
serious involvement of the skin. 

Before describing them in detail, there are certain general 
features, characteristic of the group, which require consider- 
ation. Although these vary as to the degree in which they 
are expressed, they are nevertheless of significance and of 
value in a diagnostic point of view. They may be referred 
to under the following heads. 

General Symptoms. — These, as a rule, are absent. With the 
exception of the syphilitic fever, which ushers in the second- 
ary stage of the disease and the erythematous syphiloderm, 
there are rarely signs present indicative of general systemic 

* See a discussion of this subject by Dr. Tilbury Fox, loc. cit., p. 129 ; also 
Traite de la Pellagre et des pseudo-Pellagres, par M. Roussel. Paris, 1866. 



SYPHILODERMA. 447 

disturbance. Pyrexic symptoms, consisting of loss of appe- 
tite, weakness, headache, and slight fever, are occasionally 
noted to precede certain of the diffused eruptions ; but more 
often they are not experienced, the eruption manifesting 
itself without constitutional disturbance. The patient in the 
majority of cases enjoys good general health. 

Concomitant Symptoms. — Other signs of syphilis are ordina- 
rily present with the syphilodermata. In the early eruptions, 
the chancre or its scar, induration of the inguinal glands, 
engorgement of the cervical glands, sore throat, alopecia, 
and mucous patches about the mouth and genitalia, may be 
looked for ; one or more of these symptoms will usually 
exist during the first three or four months. "With the later 
eruptions, those occurring after the first year, osteocopic 
pains, bone lesious, permanent alopecia, and other symptoms 
pointing directly to syphilis, will very often be present. 

Seat. — They confine themselves to no particular region ; 
all parts of the integument are liable to their invasion. The 
different forms of eruption, however, have decided prefer- 
ence for certain localities. The erythematous syphiloderm 
is observed to show itself most markedly upon the trunk ; 
papules are prone to develop about the genitalia and at the 
back of the neck; tubercles are most frequently encountered 
upon the face; while the palms and soles are the usual seats 
for the papulo-squamous manifestation. Symmetry is, as a 
rule, noted in the earlier, diffused eruptions only ; later, the 
distribution of the lesions is irregular. 

Multiformity of the Lesions. — They assume a great variety 
of forms of primary eruption. They manifest themselves 
as macules, papules, pustules, tubercles, and blebs, together 
with numerous modifications ; of these the papule is the 
most common. These various lesions, further, have a marked 
tendency to appear associated together. They either succeed 
one another, or, as is more usually the case, several make their 
appearance at the same time. Thus, macules and papules 
are frequently simultaneously present ; likewise papules and 
pustules. At times, especially in the early eruptions, a 
number of different lesions, including macules, papules, pus- 
tules, vesico-pustules, scales, fissures, etc., may be observed 



448 NEW GROWTHS. 

disseminated here and there over the surface. The lesions 
undergo evolution without fixed laws, a papule, for example, 
either remaining such, undergoing modification, or becoming 
a pustule; they observe no regularity of course. 

Configuration of the Lesions. — The lesions possess a marked 
disposition to appear in a circular, semicircular or crescentic 
form of arrangement. This is particularly the case in re- 
gard to the later manifestations, as, for instance, recurrent 
papules, and tubercles. 

Color. — The color varies according to the lesions, and also 
according to their stage of development. The so-called 
syphilitic tint is most pronounced in papules and tubercles, 
and may be described as being either of a brownish-red 
or yellowish-red, or copper color. The brownish-red hue, 
likened also to the color of a slice of ham, usually finds its 
expression in papules, while the yellowish-red, or copper 
color, is more apt to be observed in tubercles. 

Course. — No laws as to time govern the evolution of the 
lesions of syphilis; their course, however, is usually slow. 
They may not uncommonly be observed to pass from one to 
another ; as, for example, papules into pustules. They pos- 
sess a marked inclination to recur from time to time. They 
are non-inflammatory in character, and in this respect differ 
very materially from the exudative diseases, which they so 
frequently resemble in appearance. 

Absence of Itching. — It is only rarely that they are accom- 
panied by itching or burning sensations. As a rule, no 
subjective symptoms are present. Not infrequently indeed 
the patient is first made aware of their presence by seeing 
or feeling them. If, however, they be subjected to exter- 
nal irritation, as friction, sweat or other irritants, itching 
may occur. The small papular and pustular syphiloderm at 
times proves an exception to the rule ; it is not infrequently 
accompanied by itching. 

SyphilodermaErythematosum. — (Syn. Erythematous Syph- 
iloderm; Macular Syphiloderm; Erythematous Syphilide; 
Syphilis Cutanea Maculosa ; Roseola Syphilitica.) 

This consists in the formation of maculae of various sizes 



SYPHILODERMA. 449 

and shapes, appearing as a general eruption. They are upon 
a level with the surrounding skin, or are slightly raised, and 
are observed to disappear under pressure. In size they vary 
from a split pea to a finger-nail; they are seldom larger. 
In shape they are somewhat irregular; they may be round- 
ish, oval, or circinate. Their outline is for the most part ill 
defined; change of temperature, especially to cold, is apt to 
cause them to stand out more prominently. Some of them 
are always better defined than others. As usually seen they 
give to the skin a mottled or marbled look. The spots are 
of a pinkish or reddish color, which, however, varies con- 
siderably with their age, and also with the natural com- 
plexion of the individual. At first they are of a delicate rosy 
hue; later they become somewhat darker, usually passing 
into a dusky-pink or purplish tint. As they fade away they 
take on a pale, dirty-yellowish shade. In number they are 
always multiple ; they may exist sparsely, or, as is usually the 
case, in great profusion, and at times to such an extent as 
to cover the whole surface. Where they are present in large 
numbers they may run into one another. 

They show themselves upon all parts of the body, but are 
always seen to be particularly well marked about the trunk 
and fiexor surfaces of the limbs. The palms and soles often 
exhibit them ; the backs of the hands and feet, however, 
only rarely. The face commonly escapes. They evince no 
disposition to form into patches, circles or other arrange- 
ment; they appear without order of distribution. 

The eruption is unaccompanied by symptoms of heat or 
itching ; frequently the patient is unaware of its presence 
until it has existed for some days. 

The erythematous syphiloderm is the earliest of the syph- 
ilodermata. It generally makes its appearance from the sixth 
to the eighth week from the date at which the initial lesion, 
or chancre, was first noticed ; at times, however, it shows 
itself at a much later period. Occasionally it manifests itself 
as late as the second year, when it usually assumes the circi- 
nate form. Its appearance is retarded by treatment. It may 
show itself with or without systemic disturbance ; very often 
it is ushered in with malaise and slight fever of short dura- 

29 



450 NEW GROWTHS. 

tion, the so-called syphilitic fever. It is usually accompanied 
by other signs of syphilis, as the chancre itself or its scar, en- 
gorged cervical ganglia, erythema of the fauces, pains about 
the body, especially the joints, alopecia, and mucous patches. 

The development of the eruption is usually slow, several 
days or a week elapsing before it reaches its height; at 
times, however, it breaks forth with great rapidity and 
violence. Its appearance may be hastened by undue ex- 
citement or over-exertion. Its duration is variable; it may 
last a few weeks, a month or longer. It fades away gradu- 
ally, unattended, as a rule, by desquamation, leaving a slight 
yellowish pigmentation of the skin, which in turn likewise 
slowly disappears. Relapses may occur. 

The erythematous syphiloderm is encountered more fre- 
quently than any other form of syphilitic eruption. It is 
very common. It varies, however, exceedingly in the degree 
of its development; at times it is very pronounced, while 
in other cases it is so slight as not infrequently to escape 
detection. Treatment causes it to vanish quite rapidly. 

The diagnosis is ordinarily not difficult. It is to be dis- 
tinguished from measles, rotheln, urticaria, copaiba and 
cubebs rash, purpura rheumatica, tinea versicolor, and the 
simple erythemata. The absence of febrile and catarrhal 
symptoms, and its course, will serve to prevent its being 
confounded with measles. The eruption of measles, more- 
over, is peculiar ; it is cresceutic, and blotchy. Rotheln, or 
German measles, is characterized by small, roundish, often 
confluent, pinkish or reddish patches. It is preceded by py- 
rexic symptoms, and is accompanied by slight inflammation 
of the mucous membranes, as in measles. The eruption 
fades on the fourth or fifth day. It is an epidemic disease, 
and usually occurs in young children. 

Urticaria may always be known by its sudden appear- 
ance, the presence of wheals, the short duration of the erup- 
tion, and the constant and marked feature of itching. The 
efflorescence following the ingestion of copaiba or cubebs, 
consists of isolated or confluent urticarial patches, reddish in 
color, of short duration, and dependent upon the use of these 
drugs ; decided itching is usually present. 



SYPHILODERMA. 451 

It may be diagnosed from purpura rheumatica by the 
nature of the lesions, as well as by the history of the case. 
The macules of tinea versicolor become at times pinkish 
or reddish in color, and, where they happen to be small, 
numerous, and disseminated, may resemble the syphiloderm ; 
upon close inspection, however, they can scarcely be con- 
founded. 

Syphiloderma Papulosum. — (Syn. Papular Syphiloderm; 
Papular Syphilide; Syphilis Cutanea Papulosa.) 

This is characterized by the formation of papules, which 
vary greatly as to size, shape, distribution, and course. The 
appearances presented are altogether different as the lesions 
happen to be small or large, acuminated or flat, disseminated 
or grouped. The various stages through which they pass, 
moreover, and the modifications to which they are subject, 
give rise to symptoms which render a separate description of 
them necessary. 

Small Papular Syphiloderm. — (Syn. Miliary Papular Syphi- 
loderm ; Lichen Syphiliticus.) This form consists of an 
eruption of disseminated or grouped, more or less confluent, 
minute papules. They are pin-head or millet-seed sized; 
are distinctly elevated; and have a solid, hard, somewhat 
rough feel. In shape they are rounded and acuminated. 
Their apices may be perfectly smooth, or they may be cov- 
ered with very fine scales ; not infrequently slight pointed 
pustulation may be noticed, especially in those through 
which a hair protrudes. At first they are quite bright in 
color; later they become darker, often deep-red or brownish. 
It is apt to be a well-marked eruption, and usually occupies 
a large amount of surface, either in a disseminated manner 
or in groups, thickly studded, constituting at times almost 
solid patches. It is often seen about the neck, shoulders, 
trunk and thighs. 

It may be either an early or a late manifestation; occa- 
sionally it appears during the third and fourth month, in 
other cases not until after other lesions have occurred. It 
has a chronic course and is rebellious to treatment. It is 
more commonly met with in men than in women. Relapses 
are common. Large flat papules, as well as moist papules, 



452 NEW GROWTHS. 

may very often be found existing at the same time upon 
other regions of the body. 

It may be mistaken for lichen pilaris in those cases where 
the papules are very minute, pierced by a hair, and dis- 
seminated in great numbers over the body and extremities; 
especially in the colored race. It also bears a close resem- 
blance to lichen scrofulosus; it may, however, usually be 
diagnosed by the presence of other symptoms of syphilis. 
It is not to be confounded with papular eczema. 

Large Papular Syphiloderm. — (Syn. Lenticular Papular 
Syphiloderm.) The lesions here are large flat papules, quite 
different in size, shape, and general characteristics from the 
miliary papules just described. In size they vary from a 
small split pea to a large finger-nail or even a half-dollar. 
In shape they are generally circular or oval. They are 
firmly seated in the skin, more or less raised above the sur- 
rounding tissues, and have a flat, surface. To the touch 
they are firm and circumscribed. They are usually smooth 
and free of exfoliating epidermis. Their color is dull-red, 
and generally shows the raw ham tint; at times they are 
so dark as to have a hemorrhagic appearance. They are 
usually present in numbers, although seldom, if ever, to the 
extent of the small papules. They may show themselves 
upon all parts of the body, either as a disseminated eruption 
or confined to certain regions. They also at times group, 
and form patches. The forehead, mouth, nape of the neck, 
flexor surfaces of the extremities, scrotum, labia, perineum, 
and margin of the anus, are all favorite localities for their 
development. 

The eruption is one of the commonest of the syphiloder- 
mata. It may be either one of the earliest manifestations, 
or may first occur later. It may also appear in later years 
as a relapse. It is generally encountered closely following 
the erythematous form, and may even appear at the same 
time. The lesions, as a rule, develop themselves slowly, in 
the course of a few weeks, and attain to various sizes; they 
may usually be seen in all stages of growth. Once formed 
they are apt to remain for weeks or months. They are 
much more amenable to treatment than the small, miliary 



SYPHILODERMA. 453 

papules. They are to be diagnosed from the papules of acne 
and lichen planus. Other symptoms of syphilis will almost 
invariably be present. 

Large flat papules undergo more or less modification ac- 
cording to the locality in which they exist; other influences 
also cause them to become altered in appearance and form. 
These changes are of so marked a character as to call for 
special description ; for they are not infrequently so com- 
plete as to mask all trace of the original lesion. Their diag- 
nosis may thus become a matter of difficulty. 

As the papules progress in their course they may either 
continue to be typical lesions, and as such pass away by 
absorption, or they may metamorphose in the following 
manner: 

At times they become quite soft, spongy, and incline to 
disintegration ; when this occurs they lose their form and 
sink to the level of the surrounding skin. 

From one cause or another they may also show signs of 
excoriation, when slight crusting may take place; ulcera- 
tion, however, is seldom seen. 

Fissures not infrequently exist; they are often quite deep, 
and may be painful. They are usually observed about the 
angles of the mouth, anus, and other parts exposed to motion. 

The commonest change, however, is into the 

Moist Papule. — (Syn. Mucous Papule; Mucous Patch; 
Broad, or Flat, Condyloma; Plaque Muqueuse.) 

This takes place upon those regions of the body where 
opposing surfaces and natural folds of skin are subject to 
more or less contact. As regions in which this lesion is 
apt to occur, the nates, perineum, genitalia, groins, axillae, 
and beneath the mammae in females, may be mentioned. 
Parts influenced by excessive glandular secretion, either of 
sebum or sweat, as about the spaces between the fingers 
and toes, are also liable to be the seat of moist papules. 

The lesions differ from the large, dry papules in that they 
are more or less moist, and are covered with a whitish or 
grayish, sticky, mucoid secretion, consisting in great part 
of macerated epidermic tissue. They are also seen to be 



454 NEW GROWTHS. 

considerably flatter than dry papules, and to be very often 
without defined outline. They vary in consistence, but are 
commonly soft and of a spongy nature. Not infrequently 
several of them will have coalesced, producing a patch of 
some size; about the genitalia very large surfaces are often 
involved in this manner. 

Instead of becoming flat, they may take on action which 
results in the formation of bulky, luxuriant, hypertrophic, 
warty, papillary growths, when they are very properly 
designated "hypertrophic" or "vegetating" papules. This 
manifestation constitutes the so-called "vegetating syphilo- 
derm" (" syphilis cutanea vegetans"). It is not to be con- 
founded with the acuminated or venereal wart. (See verruca 
acuminata, p. 350.) 

Their secretion is contagious, although not auto-inoculable; 
they are, however, observed to multiply abundantly in those 
regions favorable for their development simply by the pres- 
ence of the irritating secretion. They are notable for the 
rapidity with which they develop and increase in size. They 
are a luxuriant growth. Heat, moisture, friction, unclean- 
liness, all contribute towards their development. They are 
quite amenable to treatment. Local measures usually act 
very promptly in causing them to disappear. 

To return to the dry papules. Very frequently after 
having fully developed, or even in their early stage, quite 
another and different change may be established, namely, a 
process of extensive desquamation ; when this takes place 
they become "squamous papules." This modification is a 
very common one, and constitutes the 

Papulosquamous Syphiloderm. — (Syn. Squamous Syphilo- 
derm: Syphilis Cutanea Squamosa; Psoriasis Syphilitica.) 

This manifestation is always developed from the papule. 
It presents different appearances as it occurs in one locality 
or another, and according to the arrangement of the lesions. 
The papules may be isolated, grouped or closely packed to- 
gether forming solid patches. They are seen to be somewhat 
flattened, and to be covered with a dry, grayish, adherent 
scale; it may be quite thin and scanty or relatively abundant, 



SYPHILODERMA. 455 

although never so luxuriant as in psoriasis. If the scales are 
removed, elevated or flattened papules, dull red in color, 
more or less perfectly defined, may be detected. The erup- 
tion is seldom extensive; may show itself upon any portion 
of the body, with preference, however, for the palms and 
soles ; and is remarkably persistent in its course. 

Owing to the peculiarity in the structure of the skin of 
the palms and soles, the disease assumes here an appearance 
altogether different from that seen elsewhere. It is known 
as the " palmar" and "plantar" syphiloderm, and is entitled 
to special description. The lesions very often partake rather 
of the nature of macules than of papules, yet the character- 
istics are such as to permit of no doubt concerning their 
anatomy ; they are modified papules. They consist of pap- 
ules slightly raised above the level of the surrounding skin, 
but, as a rule, imperfectly defined to the touch. In size they 
vary ; they may be split-pea sized or as large as a finger-nail. 
In shape they are irregular, and on account of their tend- 
ency to coalesce are seen in the form of roundish, linear, 
serpiginous or crescentic patches. They are covered with 
dry, scanty, semi-detached flakes of epidermis, which have 
a grayish color. These are very adherent, and are observed 
to be most abundant about the edge of the patch, where 
they usually have a wrinkled or dried-up appearance. If the 
scales be removed the surface beneath will be found, usually, 
of a deep-red color. At times the exfoliation of epidermis 
takes place quite abundantly and presents a distinctly squa- 
mous patch ; it may either be cast off, or remain upon the 
surface, in which event it gives a hard, horny coating to the 
part. In other cases little or no desquamation occurs, the 
patch presenting a strictly erythematous look. The patches 
may either be hard or soft to the feel, according to the form 
in which the lesion shows itself; the more circumscribed the 
papule or deposit, the greater will be its firmness. In ad- 
dition to the lesions described, fissures usually exist, extend- 
ing at times deep into the corium. 

The eruption is usually symmetrical, and is apt to appear 
in the centre of the palm or sole, upon the ball of the thumb, 



456 NEW GROWTHS. 

and about the volar surfaces of the fingers. The outer sides 
of the palms and soles are also frequently invaded. It rarely 
attacks the backs of the hands or feet; nor does it usually 
spread extensively, as, for example, over the wrist. It may be 
limited to a small patch the size of a coin, or it may involve 
the greater part of the surface. As a rule, neither heat nor 
itching is present. Its course is exceedingly chronic, fre- 
quently lasting months and years. It is rebellious to treat- 
ment. It may appear either as a comparatively early or as a 
late manifestation. If it occur upon only one hand or foot, it 
is apt to be a late eruption, often years after the initial lesion. 

The papulo-squamous syphiloderm is very liable to be con- 
founded with eczema and psoriasis; also with callosities. 
From eczema it may always be distinguished by the absence 
of heat, itching, and discharge, the two former of which 
symptoms are always present in eczema. The course of the 
eruption, and its history, will also be of assistance in the 
diagnosis. 

It often resembles psoriasis very closely, whether occurring 
upon the trunk, extremities, or palms and soles. The dif- 
ferential diagnosis may be stated as follows: The syphilo- 
derm is almost always confined to adult age, and is the result 
of acquired syphilis; psoriasis frequently manifests itself in 
early life, 'usually before the age of twenty. In connection 
with the syphiloderm there is generally some clue to the 
initial lesion of syphilis; on the other hand, in psoriasis, a 
clear history of psoriasis is ordinarily obtainable. 

The syphiloderm, though very persistent and stubborn in 
its course, when once entirely removed by treatment, is not 
apt to return; the tendency of psoriasis is to recur at inter- 
vals through life. 

The patches of the syphiloderm have no tendency to form 
into a regular system of configuration; they may take upon 
themselves any pattern as to outline, and usually vary their 
shape according to locality. Very frequently, however, the 
papules composing the patch assume a circular or semi- 
circular arrangement; this is usually more noticeable where 
the eruption is limited in extent. Psoriasis, on the other 



SYPHILODERMA. 457 

hand, almost invariably inclines to assume some definite pat- 
tern for its patches. 

The edges of the patches of the syphiloderm are generally 
elevated, and possess a marked line of demarcation ; the dis- 
ease is observed to terminate abruptly against the healthy 
skin. This margin may often be detected by passing the 
finger over its surface ; it is the line of the plastic syphilitic 
deposit. Upon the palm or sole it is generally less defined 
than on other parts of the body. The edges here are, as a 
rule, only slightly raised, but are apt to be covered with a 
film-like, shrivelled scale. In psoriasis, the elevation of the 
patch and its border are due to the scales; if these be thor- 
oughly removed, a red, shining surface, not much, if at all, 
raised above the level of the skin, is observed. 

The syphiloderm, except when it attacks the palms and 
soles, and even here it is subject to variation, has no tend- 
ency to occur symmetrically. Psoriasis generally manifests 
a disposition to symmetry. 

The syphiloderm ordinarily confines itself to one portion 
of the body, the amount of surface involved being usually 
small in extent; it rarely occurs upon the elbows or knees. 
Psoriasis attacks remote parts of the body simultaneously, 
and has a strong predilection for the elbows and knees. 

Both the syphiloderm and psoriasis may invade the palms 
and soles ; both diseases may also appear exclusively upon 
either the palms or soles, the rest of the body remaining en- 
tirely free. When psoriasis, however, exists upon the palms 
or soles, it is common to see it at the same time on other 
portions of the body. When the syphiloderm, on the other 
hand, attacks the palms or soles, it is the rule to find no trace 
of it elsewhere. 

Slight itching may be present with the syphiloderm, par- 
ticularly if seated on the trunk, but rarely to such an extent 
as to cause the patient to scratch. Psoriasis is very apt to be 
attended with more or less itching ; at times it is marked, 
especially if the attack be acute. 

The syphiloderm increases its area step by step, and is 
usually very slow in its course; psoriasis is a more active 
process, and often extends itself with rapidity. 



458 NEW GROWTHS. 

The syphiloderm manifests its presence in the form of 
a deposit in the tissue; in psoriasis there is no deposit, 
but simply a hyperplasia of the cells of the rete, attended 
with inflammatory symptoms. This difference in the path- 
ological structure of the patches is generally appreciable 
even to the naked eye, and constitutes one of the most val- 
uable diagnostic signs between the two diseases. Exclusive 
of the scales, there is but little thickening of tissue in the 
ordinary patch of psoriasis ; in syphilis there is decided infil- 
tration throughout the skin. Care should be exercised in 
discriminating between the thickening due to inflammatory 
swelling in psoriasis, and that arising from the plastic for- 
mation of syphilis. 

The syphiloderm usually consists of more than one kind 
of lesion, a variety indeed being at times observable, com- 
posed of papules, fissures, ulcers, and scales; in psoriasis all 
the patches of the disease show the same pathological char- 
acters. A patch of psoriasis is made up of a circumscribed 
inflammatory surface, which is always covered with scales. 

The color of the syphiloderm is usually less vivid and 
bright than that of psoriasis ; it has a dull, smoky, brownish- 
red hue. 

The scales of the syphiloderm always have a yellowish, 
dirty-white, dingy, old, dried or shrivelled look; in psoriasis 
they are silvery white, glistening, mother-of-pearl colored, and 
have the appearance of being new and fresh, as though they 
had been recently formed. In syphilis they are formed very 
slowly, and exist scantily ; in psoriasis they are produced 
rapidly, and are usually present in great quantity. This 
point of difference is valuable for diagnosis. In syphilis, 
moreover, the scales are thin and adherent; in psoriasis 
they are loose, non-adherent, and easily detached 'from their 
bed. A patch of syphilis may readily be denuded of its 
scales without provoking blood; a psoriatic patch will bleed 
very much more easily under the same circumstances. 

In syphilis the papules may break down and show signs of 
moisture or superficial ulceration ; in psoriasis the process is 
always a dry one throughout its course. Finally, in doubtful 
cases, treatment will aid in the diagnosis. 



SYPHILODERMA. 459 

Syphiloderma Yesiculosum. — (Syn. Vesicular Syphilo- 
derm ; Vesicular Syphilide; Syphilis Cutanea Vesiculosa.) 
This is an unimportant and rare manifestation. Vesicles are 
seldom encountered in syphilis. In the majority of instances, 
so-called syphilitic vesicles may be more property viewed as 
early pustules ; occasionally, however, the lesions are of 
such character throughout their course as to be entitled to 
the term vesicular. The vesicular syphiloderm has been 
described at length by Bassereau* and Hardy, f 

The lesions vary in size, form, arrangement, and distribu- 
tion. They may be small, millet-seed or pin-head in size, 
more or less acuminated, and disseminated or grouped ; or 
they may be split-pea sized, flat or semiglobular, with or 
without umbilication. The small, miliary vesicles manifest 
themselves as irregularly grouped or disseminated lesions, 
inclining to involve the hair follicles, and are succeeded by 
minute, yellowish, granular crusts. They very frequently 
pass into miliary pustules. The larger vesicles are apt to 
occur as a disseminated eruption and show a disposition to 
assume the form of the vesicle of varicella, whence the term 
"varicellaform syphiloderm." The lesions here are usually 
split-pea sized, slightly umbilicated, contain a clear or cloudy 
fluid, are surrounded with a more or less marked coppery 
areola, and are remarkable for their persistency, at times re- 
maining days without undergoing appreciable change. They 
may be isolated or confluent. At times they group in a cres- 
centic manner. They are succeeded by a light-yellowish or 
grayish crust, which, as a rule, is not large. 

The vesicular syphiloderm shows itself in localities where 
the skin is naturally thin, as on the face and about the geni- 
talia. It is rarely extensive in its distribution, nor are the 
lesions apt to be numerous. Its course is usually rapid. The 
lesions terminate either in absorption or in rupture and slight 
crusting. It seldom exists alone; papules, either large flat 
or small, are usually present over other regions of the body; 

* Traite des Affections de la Peau symptomatiques de la Syphilis. Paris, 
1852. 

f Lecons sur la Scrofule et les Scrofulides et sur la Syphilis et les Syphilides. 
Paris, 1864. 



460 NEW GROWTHS. 

other signs of syphilis are also generally present. As origi- 
nally pointed out by Bassereau, it is an early eruption, occur- 
ring during the first year, and usually within the first six 
months. 

Sypiiiloderma Pigmentosum. — This affection, the so- 
called " pigmentary syphilide" of the French, has been de- 
scribed by Hardy,* and more recently by Fournier,f two 
most accurate observers. I have never met with it, and 
consequently have no personal experience to present. Ac- 
cording to these writers, it consists of a circumscribed pig- 
mentation of the skin, in the form of roundish, oval or 
irregularly-shaped, split-pea or finger-nail sized, discrete or 
confluent macules. They are on a level with the surround- 
ing skin, and have a smooth surface like that of normal 
skin ; they are, in fact, simple pigmentary deposits. They 
have a grayish-yellow, pale, weak coffee- vvith-milk color. 
Not infrequently the color is so faint that the lesions at first 
escape detection. They usually have the appearance of being 
dirt-marks, rather than disease. The lesions are generally 
ill defined, and are apt to coalesce, forming an irregular, 
more or less broken patch of discoloration. The surface is 
said to present an indistinctly marbled look. 

The affection is unaccompanied by subjective symptoms; 
there is neither heat nor itching. It is most frequently en- 
countered upon the neck, upon one or both sides; according 
to Fournier it occurs here as often as twenty-nine times out 
of thirty. It is also occasionally met with on the thorax, 
abdomen, and limbs. The manifestation is peculiar in that 
it shows itself almost exclusively in women ; it is very rarely 
met with in men, and only in those possessing thin, trans- 
parent, delicate skins. It is encountered during the latter 
half of the first and in the second year of the disease. It is 
rare. 

Its course is slow; it may continue two or three months 
or from one to two years. Oddly enough, it is uninfluenced 
by anti-syphilitic treatment, neither mercury nor iodide of 

* Loc. cit., p. 175. 

f LeQons sur la Syphilis, etudiee plus particulierement chez la Fenime. 
Paris, 1873, p. 422. 



SYPHILODERMA. 461 

potassium having any effect in causing its disappearance. 
Notwithstanding this peculiarity, the manifestation is, ac- 
cording to both Hardy and Fournier, unquestionably due to 
syphilis. It occurs in syphilitic subjects only. In its nature 
it is a simple pigmentary formation, probably differing in no 
way from chloasma. 

It may be mistaken for chloasma uterinum, vitiligo, len- 
tigo, and tinea versicolor. From the latter disease it may 
be known by its having a smooth, non-desquamative surface. 
No satisfactory treatment has been suggested. 

Syphiloderma Pustulosum. — (Syn. Pustular Syphiloderm; 
Pustular Syphilide; Syphilis Cutanea Pustulosa.) The pus- 
tular syphilodermata constitute an important group. Al- 
though not so common as the erythematous and papular 
manifestations, they are nevertheless very frequently en- 
countered. They appear in a variety of forms, the lesions of 
which differ in size, shape, number, distribution, and other 
features.' Before describing these in detail I shall speak of 
them as a group. 

The pustules vary greatly in size. They may be no larger 
than a millet-seed, or, on the other hand, they may be split- 
pea sized or as large as a finger-nail. In shape they likewise 
vary ; at times they are circular, in other cases they are oval 
or irregular in outline. In form they are acuminated, as in 
acne and variola, or flat, as in ecthyma. Very often they 
are seated upon a distinctly indurated papular base; in other 
instances they are surrounded by extensive areolae, and are 
but little elevated above the level of the surface. They vary 
greatly as to number; they may be few, or, on the other 
hand, very numerous. They may be disseminated or grouped ; 
usually they are dispersed over the surface without regularity 
of distribution. 

They either begin as pustules, or, beginning as papules, 
vesicles or vesico-pustules, sooner or later become pustules, 
which in a variable time terminate in crusting. From the 
decided inclination to crust formation which the larger pus- 
tules evince early in their course, they have been termed by 
the French " pustulo-crustaceous" lesions. The crusts usu- 
ally begin to form shortly after the lesions manifest them- 



462 NEW GROWTHS. 

selves ; in some instances the crusts form simultaneously with 
the pustules. As a rule, the larger the pustule, the sooner 
will the process of crusting begin. 

The crusts either correspond in size and shape with the 
pustules which have preceded them, or they may be con- 
tracted and smaller than the original lesion. They may be 
acuminated or broad; raised and bulky or flat and superficial. 
In consistence they are either soft, or, as is usually the case, 
hard and smooth. The larger and more bulky crusts incline 
to become stratified like the exterior surface of an oyster- 
shell. In color they vary from yellow to brown or even 
black, and when of any size and depth incline to assume 
an olive-greenish hue. 

Beneath the crust there always exists an ulcer; this may 
be superficial or deep, according to the general character of 
the primary lesion. The edges are usually sharply defined, 
giving the ulcer a punched-out appearance. The base of the 
ulcer, when large, is generally covered with an abundant, 
grayish, yellowish or greenish, puriform secretion. The 
lesions are followed by pigmentation, and usually marked 
cicatrices. 

As regards the time at which the pustular syphilodermata 
manifest themselves, they may be either an early or a late 
eruption. They may be benign or malignant. 

The following varieties may be described : 

Small Acuminated Pustular Syphiloderm. — (Syn. Miliary Pus- 
tular Syphiloderm.*) 

The pustules are millet-seed in size. They are raised above 
the level of the skin, and are observed to be seated upon 
minute, reddish, papular elevations. They are acuminated 
in form, and contain an exceedingly small amount of fluid, 
more or less puriform in character, w T hich in time dries into 
adherent yellowish or light-brownish crusts. After the crust 
has fallen oft', slight desquamation or exfoliation is apt to 
take place, which usually manifests itself in the form of a 
delicate, thin margin or fringe of epidermis around the base 
of the lesion, constituting a minute, grayish ring or collar 

* Herpetiform Syphilide of the French. 



SYPHILODERMA. 463 

(the "collerette" of the French). The hair follicles are very 
commonly involved, hairs penetrating through the centre of 
the lesions. 

The eruption is almost always abundant, the pustules ex- 
isting in very great numbers, either discretely or continently, 
irregularly disseminated or in groups, over various regions. 
Sometimes they are arranged in the form of more or less 
well-defined circles and semicircles. It usually invades a 
large tract of surface; at times, however, it is localized, as 
often occurs in the case of a relapse. The extremities, es- 
pecially the arms and thighs, the chest and the back, are 
its favorite localities. With the eruption are usually found 
miliary papulo-pustules and papules; not infrequently these 
are numerous, and show the various stages of the evolution 
of the pustule from the papule. Miliary vesicles, as well as 
large flat papules, are also at times present. 

The miliary pustular syphiloderm may occur either as an 
early eruption or, in the form of a relapse, as a late second- 
ary manifestation ; at times it is met with in the third or 
fourth month. Uninfluenced by treatment it runs a slow 
course. Relapses may occur. It disappears leaving a deep 
pigment deposit, of a bluish-red or brownish color. After 
the lesions have passed away, minute pin-point or pin-head 
depressions in the skin remain, which in time become ef- 
faced. The diagnosis of this syphiloderm is not difficult. 
Other symptoms of syphilis usually accompany the eruption. 

Large Acuminated Pustular Sypkfloderm. — [Sim. Acneform 
Syphiloderm; Acne Syphilitica; Variolaform Syphiloderm.) 

The eruption is characterized by small or large split-pea 
sized, more or less acuminated pustules, similar in general 
features to those of simple acne or of variola. The crusts, 
which form sooner or later, are yellowish or brownish in 
color, small and thin, and seated upon superficial ulcers. It 
may develop itself rapidly with fever, or slowly. The lesions 
usually occur in large numbers, and are generally dissemi- 
nated. They are met with upon the scalp, face, and trunk; 
more rarely upon the extremities. Other syphilitic lesions 
are apt to be present, as, for example, papules. 

It is one of the earliest of the pustular syphilodermata, and, 



464 NEW GROWTHS. 

as a rule, pursues a rapid and benign course. It is not a 
common form of eruption. I have encountered it more 
often in the colored than in the white race. 

It is to be distinguished from simple acne, from the erup- 
tion of the iodide of potassium, and from variola. In the 
colored race it not infrequently closely resembles variola. 

Small Flat Pustular Syphiloderm. — {Syn. Impetigoform Syph- 
iloderm ; Impetigo Syphilitica; Pustular Eczemaform Syphi- 
loderm.) 

The pustules are generally small, flat, and grouped into an 
irregularly-shaped patch, the size of a coin or larger; they 
are seldom disseminated. Crusting begins almost imme- 
diately, rendering the lesions markedly pustulo-crustaceous. 
The crusts are more or less adherent; and are thick, bulky, 
uneven, and irregularly heaped up. They are dry, and in- 
cline to become granular and to crumble. In color they are 
yellowish, greenish-yellow or brownish; they resemble the 
crusts of pustular eczema. 

Where the pustules have coalesced, a continuous sheet of 
crust is apt to form, as in pustular eczema. The ulcer be- 
neath the crust may be superficial or deep. The eruption 
is usually encountered about the face, especially around the 
nose and mouth and on the hairy parts of the face, and on 
the scalp ; also about the genitalia. It is generally benign ; 
occasionally, however, it assumes a malignant action, the 
ulceration extending deeply, and spreading over considerable 
surface in a more or less serpiginous manner. 

The affection resembles pustular eczema, and may readily 
be confounded with it if the character of the erosion or ulcer 
be not taken into consideration. The diagnosis can with 
difficulty be made from the appearance of the crusts alone. 

Large Flat Pustular Syphiloderm. — {Syn. Ecthymaform Syph- 
iloderm; Ecthyma Syphiliticum.) 

This appears in the form of large, finger-nail sized, flat 
pustules, seated upon a deep-red base. The pustules seldom 
remain as such for any length of time, but incline to crust 
immediately. Two varieties of this eruption are met with, 
the superficial and the deep. In the former the crust is flat, 
roundish or oval, adherent, and of a yellowish-brown or 



SYPHILODERMA. 465 

brown color. It is seated upon a superficial ulcer or erosion, 
having a grayish or yellowish, abundant secretion. The 
lesions are usually numerous and may appear upon any part 
of the body, although they have preference for the back, 
shoulders, and extremities.* It is a common manifestation, 
and runs a benign course. It is apt to occur in the first year, 
after the sixth month. 

The deep variety possesses a raised and more bulky crust, 
which inclines to become conical, is harder in consistence, 
and has a greenish or blackish color. The prominent, strati- 
fied, oyster-shell-like crust often observed constitutes the 
condition known as rupia. This is also met with in connec- 
tion with the bullous syphiloderm. Rupia, therefore, may be 
the result either of the pustular or of the bullous eruption of 
syphilis. Beneath the crust the ulcer is seen to be excavated, 
punched out, and to be covered' with an unhealthy, greenish, 
puriform secretion. It is a late and malignant manifestation. 
It is seldom met with outside of hospital practice. 

Syphiloderma Tuberculosum. — (Syn. Tubercular Syphilo- 
derm; Tubercular Syphilide; Syphilis Cutanea Tuberculosa.) 
The eruption here consists of one or more solid elevations of 
the skin, varying in size from a split pea to a hazelnut. They 
are circumscribed, rounded in form, acuminated or dome- 
shaped, and have usually a smooth, somewhat glistening sur- 
face. They are hard and firm to the touch, and are felt to 
be quite deeply seated in the skin. In color they are deep- 
red or brownish-red ; at times they have a yellowish-red, 
distinctly coppery tint. Not infrequently they have an in- 
tensely red, lurid hue, a color not met with in any other 
disease of the skin. 

They may be either single or multiple, usually the latter, 
although they rarely occur in very great numbers. If small 
they are more apt to be numerous. They seldom appear 
over the whole body, but are generally confined to certain 
regions. They may be either disseminated or grouped; 
when in large numbers they tend to form more or less solid 
tubercular patches. As to their arrangement, they may be 

* See Plate D, Syphiloderma (Pustulosum), author's Atlas of Skin Diseases. 



466 NEW GROWTHS. 

either irregularly disposed or grouped in the form of seg- 
ments of circles and semicircles. When the latter arrange- 
ment occurs, the patches are very apt to coalesce, forming a 
serpiginous tract of disease ("serpiginous tubercular syphilo- 
derm"). The parts of the body which are commonly invaded 
are the various localities of the face, the back, and, more 
rarely, the extremities. They are unaccompanied by pain, 
heat, or itching. Their development is slow, usually extend- 
ing over some weeks or months. They are always to be 
viewed as a late manifestation of syphilis; they rarely, if 
ever, show themselves before the second year, and generally 
not until later; often not before five, ten, fifteen or twenty 
years after the initial lesion. Other symptoms of the dis- 
ease will almost invariably have occurred before they mani- 
fest themselves. 

They disappear in two ways, either by absorption or ulcer- 
ation. They may ulcerate superficially or deeply; usually 
the latter. The process may commence upon their summits 
or in their interior, the result being a more or less complete 
destruction of the lesion, causing an ulcer of variable size. 
The ulcer is usually seen as a deep, punched-out cavity, with 
irregular edges, horse-shoe or crescentic in shape, covered 
with a grayish-red deposit of gummy matter, or with a 
yellowish or brownish crust. 

Papillary formations at times spring up from ulcerating 
tubercles, in the form of wart-like, cauliflower excrescences, 
accompanied by the secretion of a yellowish, puriform, of- 
fensive product. ("Syphilis cutanea papillornatosa.") The 
same growth may occur with the gummatous ulcer. 

Ulceration may also attack a patch of grouped tubercles, 
the result being an extensive excavation involving at times 
the whole affected surface. Not infrequently the process 
assumes a serpiginous course, extending itself in an irregu- 
lar, serpentine manner ; the ulceration is usually accom- 
panied by a certain amount of simultaneous cicatrization, 
and is apt to be very disfiguring in its results. It is often 
encountered on the back, and is generally obstinate. 

The tubercular syphiloderm is to be diagnosed from lupus 
vulgaris, from elephantiasis Grsecorum, and from carcinoma. 



SYPHILODERMA. 467 

It is most liable to be confounded with lupus vulgaris. The 
tubercles of syphilis, however, are harder, more deeply 
seated, and have a history of more rapid development. The 
characteristic features of lupus, moreover, are wanting. 
Lupus appears usually first in childhood; the tubercular 
syphiloderm is rarely seen before adult or middle age. 

Syphiloderma Gummatosum. — (Syn. Gummatous Syphilo- 
derm ; Gummatous Syphilide ; Syphilis Cutanea Gumma- 
tosa.) This is characterized by the formation of a roundish 
more or less circumscribed growth situated in the subcu- 
taneous tissue, showing its presence upon the surface as a 
slightly-raised, dome-shaped tumor, variable as to size, of an 
elastic, moderately firm consistence, tending in its course to 
break down into an ulcer. The formation is known as a 
"gumma," "gummy tumor" or "syphiloma." It begins as 
a small, pea-sized, soft, ill-defined, painless body, which is 
felt to be beneath the skin ; it is usually loosely imbedded 
in the tissues and may be moved about under the finger. 
The skin at this time is not altered in color, nor is the 
outline of the growth usually discernible. The deposit in- 
creases slowly in volume, until, through a period of weeks or 
months, it finally assumes definite shape and consistence. 
It is now seen to be a more or less rounded tumor, imbedded 
in the subcutaneous tissues. In size it may vary from a 
hazelnut to an egg; most frequently it is seen to be about 
the size of a walnut. The skin is more or less involved and 
appears pinkish, reddish or purplish. In shape the growth 
shows itself upon the surface as a slightly-elevated semi- 
globular, uniformly organized body. To the touch it has a 
soft, doughy, somewhat elastic, feel. 

Gummata rarely exist in numbers. One or two only are, 
as a rule, present at the same time; occasionally they are 
multiple, but such instances are of infrequent occurrence. 
They may appear upon any part of the body ; their tendency, 
however, is to develop in the looser and softer tissues, as 
upon the flexor surfaces of the extremities, abdomen, and 
sides of the thorax; they also occur upon the head. The 
palms and soles are rarely, if ever, attacked. 

The gumma tends to break down, ulcerate, and destroy 



468 NEW GROWTHS. 

the tissues in which it has its seat. The ulcer is seen as 
a circumscribed, deep excavation, usually rounded in form, 
with abrupt, perpendicular edges. It may be the size of a 
finger-nail or as large as the palm of the hand. Its bottom 
is generally uneven, and is covered with a grayish-red stringy 
or gummy deposit. The skin is always completely destroyed, 
likewise, to a great extent, the subcutaneous connective tissue 
and deeper structures. Disintegration, as a rule, progresses 
slowly ; crusting, consequently, is unimportant. The loss 
of tissue is very often great, although cicatrization usually 
takes place in such a manner as to leave a comparatively 
insignificant scar. In place of ulceration, the growth may 
disappear by absorption. 

The gumma is to be distinguished from furuncle and from 
abscess; from enlarged lymphatic glands; from carcinoma; 
and from fibrous and fatty tumors. The ulcer resulting from 
the disintegration of the gumma will be diagnosed from the 
non-syphilitic ulcer by the history, the depth of the ulcer, 
its sharply-defined edges, its punched-out appearance, the 
character of the secretion, the absence of pain, and the pres- 
ence, in many cases, of other symptoms of syphilis. 

Syphiloderma Bullosum. — (Syn. Bullous Syphiloderm ; 
Bullous Syphilide; Syphilis Cutanea Bullosa; Pemphigus 
Syphiliticus.) The eruption is characterized by the forma- 
tion of blebs containing a clear, watery fluid, which, in the 
majority of cases, tends to become soon cloudy and thick. 
At times the lesions partake more of the nature of pustules 
ithan of blebs. In size they vary from a pea to a walnut; it 
is usual to encounter them of all sizes and in various stages 
of development. They are discrete, disseminated, circular 
or oval in form, and are surrounded usually with a slight 
areola. The walls of the bleb may be fully or only partially 
distended ; after lasting a variable time they break, and the 
contents dry into brownish or dark greenish crusts. 

The crusts vary considerably in their form; at times they 
are very large, bulky, raised, conical, and furrowed upon 
their surface like the outside of an oyster-shell. This pe- 
culiar crust formation is known as rupia. (See large fiat 
pustular syphiloderm.) In other cases they are smaller, 



SYPHILODERMA. 469 

flatter, and less bulky. Beneath the crusts, which may 
usually be removed without difficulty, are seen distinct 
erosions or ulcers, with sharply-defined edges, secreting a 
copious, creamy, greenish-yellow fluid. They are followed 
by extensive, more or less pigmented cicatrices. The course 
of the eruption is variable, depending very materially upon 
the general condition of the patient. 

The bullous syphiloderm is a late manifestation, and is 
usually accompanied by other symptoms of the disease. It 
is rare. It is seen for the most part upon cachectic, broken- 
down individuals. It also occurs in the new-born, as the 
result of inherited syphilis, when it often closely resembles 
pemphigus vulgaris. (See hereditary syphilis.) The char- 
acter of the bullae and of the subsequent crusts will serve 
to distinguish it from pemphigus ; other signs of syphilis, 
moreover, will usually be noted. 

Syphiloderma ILereditarium Infaxtile. — The cutaneous 
manifestations of hereditary syphilis in the infant present 
a somewhat different appearance from those of acquired 
syphilis, and are therefore entitled to separate description. 

Syphilis in the newborn may be hereditary, that is, the 
child may have become infected in utero through the influ- 
ence of the mother or father, or of both parents; or it may 
be acquired, the disease being contracted at any period after 
leaving the uterus, either during delivery or after birth. 
When acquired, it runs precisely the same course as in the 
adult. The terms " congenital" and " infantile'' syphilis 
are indefinitely used to express the existence of the disease, 
without reference to its having been inherited or acquired. 

A child the subject of hereditary syphilis may be bora 
either apparently sound or in an obvious state of disease. 
The majority of syphilitic infants are born to all appear- 
ances healthy, the disease not showing itself until a later 
period, in almost all cases, however, within the first three 
months. According to Diday,* who has collected 158 re- 
ported cases of hdeditary syphilis in infants, the disease 

* A Treatise on Syphilis in Newborn Children and Infants at the Breast, 
p. 101, New Syd. Soc. Translation. London, 1859. 



470 NEW GROWTHS. 

manifested itself before the end of the first month after birth 
in 86 cases, and before the completion of the second month 
in 45 cases, while in the third month there were but 15 cases. 
It will be seen from these statistics that the disease usually 
makes its appearance before the end of the second month, 
and that after the fourth month the chances are in favor of 
the child having escaped infection. 

On the other hand, infants may come into the world with 
the imprint of syphilis stamped upon them in the form of 
the maculo-papular or bullous eruption, or with the general 
signs of syphilitic cachexia and marasmus. These cases 
rarely live longer than a few days or weeks. 

When the child is born with a clean skin and apparently 
healthy, syphilitic symptoms are not apt to manifest them- 
selves before the second or third week; often it is later. 
The child during this period either remains well or shows 
signs merely of general debility. At birth the infant may 
be stout and well nourished, or it may be spare, puny, and 
delicate. Usually in the course of two or three weeks it 
begins to exhibit unmistakable evidence of failing in health. 
It grows thinner and weakly, is fretful, or cries peevishly, 
wastes away, and becomes greatly changed in appearance. 
From a well-nourished infant it has in a short time be- 
come emaciated and plainly diseased. The skin now as- 
sumes a peculiar dingy, yellowish, earthy or muddy hue. 
The cutaneous tissues are deprived of their fat; the bones 
are prominent; while the skin is harsh, dry, thin, and more 
or less wrinkled, forming lines and furrows, which are apt 
to be particularly noticeable about the face. These changes 
give to the little patient a pinched, wizened, dried-up aspect, 
resembling that of an old man or woman. 

One of the first specific symptoms noticed is coryza, 
which is usually present at this stage of the disease. The 
discharge at first is thin and watery, but soon becomes 
thicker and tenacious, gradually accumulating in the nasal 
passages. In a short time the nares become stopped up^ 
a collection of mucus and crust taking place around the 
orifices; the breathing is interfered with; and a peculiar 
snuffling noise is heard, which is quite characteristic. At 



SYPHILODERMA. 471 

times the nostrils are occluded to such an extent that 
breathing can take place only through the mouth, in which 
event it is with the greatest difficulty that the child is able 
to suck. Later, the discharge from the nares becomes more 
or less sanious and has a penetrating, fetid odor, and mucous 
patches appear about the nares and around the mouth. If 
the disease continue, the small bones of the nose may be 
involved, caries occurring, with discharge of fragments of 
bone, followed by deformity of the nose. With the coryza 
there is generally more or less hoarseness, and at times even 
aphonia, the throat being attacked in a similar manner by 
erythema and mucous patches. The cry of the child at this 
stage of the disease is peculiar. 

The lesions upon the skin may manifest themselves before 
the coryza, simultaneously with it, or later ; usually they 
appear at about the same time. Not rarely, however, the 
skin is the first tissue attacked. The eruption may appear 
in the form of erythema, papules or blebs, or as a mixture 
of these lesions. The most frequent manifestation consists 
of both macules and papules. Not infrequently the first 
cutaneous symptoms are erythematous patches and spots, 
varying in size from a finger-nail to the palm of the hand, 
occupying the buttocks, thighs or genitalia. They are 
usually irregularly shaped; have a more or less indistinct 
outline; are deep-red, brownish-red or coppery in color; 
somewhat shining, or covered with a thin, ragged epider- 
mis ; and are either dry and squamous or slightly moist 
and excoriated. At times these patches are very exten- 
sive and involve the whole of the lower portion of the 
trunk and the thighs in one continuous sheet of erythema. 
The coloring in these cases is not infrequently of an intense, 
deep yellowish-red. The early stage of this erythematous 
manifestation very often closely resembles simple erythema 
intertrigo, so much so that the diagnosis may be difficult. 
In a short time the lesions become more marked, the patches 
become thickened, and distinct macules appear here and 
there over the surface, which either remain such or pass 
into flat papules. In other cases the palms and soles are first 
attacked by the erythema, the epidermis beginning at once 



472 NEW GROWTHS. 

to exfoliate in the form of thin, dry, ragged pieces or layers. 
It will thus be noted that the erythematous syphiloderm of 
hereditary syphilis differs considerably in appearance from 
that of acquired syphilis. 

Usually in the course of a few weeks the erythematous 
patches become the seat of broad, flat papules, the size of a 
Anger-nail and larger, the eruption thus becoming maculo- 
papular. This may be considered as the commonest syphilo- 
derm in the infant. The papules exist as both dry and moist 
lesions, the latter form predominating, especially about the 
genitalia and natural folds of the skin. They are usually 
large, not infrequently of the character rather of patches of 
infiltration ; often but slightly raised above the level of the 
surrounding skin ; and are smooth and glazed, or are covered 
with a pellicle or scale. The moist papule, or mucous patch, 
is one of the earliest symptoms of hereditary syphilis ; it is 
also one of the commonest manifestations. These lesions 
first make their appearance about the nose, mouth, anus, 
and genitalia. They are also very frequently met w T ith about 
the toes and fingers, umbilicus, axillae, backs of the ears, 
and in other natural furrows of the integument, particularly 
where friction, heat, and moisture are apt to exist. Together 
with moist papules occur fissures, varying in length and 
depth, secreting a viscid or sanious, offensive product, which 
tends to crust and to mask the true lesion. Papules, more- 
over, not infrequently excoriate, break down, and ulcerate 
superficially. 

Mucous patches occurring in the mouth may be con- 
founded with aphthae, or thrush, which often bears a close 
resemblance to the syphilitic lesion. Aphthae may be dis- 
tinguished by being seated upon an inflammatory base, and by 
their oval or circular shape with distinct margins and areolae. 
They usually occur in successive crops and in groups, and 
are, moreover, generally attended by gastric derangement. 
The affection is due to a vegetable parasite, the o'idium albi- 
cans, which may be demonstrated under the microscope, 
thus, in doubtful cases, determining the diagnosis. 

The bullous syphiloderm in the infant usually manifests 
itself at birth ; is, in fact, already developed when the child 



SYPHILODERMA. 473 

comes into the world. It may, however, first show itself 
later. It consists of variously-sized, flat or semi-globular, cir- 
cular, oval, or irregularly-shaped, distended or flaccid blebs 
or pustules, scattered over the surface. They possess a de- 
cided disposition to attack the palms and soles, and fingers 
and toes; also the limbs. They show no regularity of form, 
and are usually present in all stages of development from 
the bleb to the pustule. Their contents may be clear or 
cloudy, turbid and sanious. They are seated upon patches 
of reddish, unhealthy-looking skin, and are sometimes sur- 
rounded by bluish or purplish areola?. They may be present 
in large numbers or they may be sparse. Sooner or later they 
break or are ruptured by violence, and show an excoriated 
or ulcerated, dark-reddish or purplish base, which is slow to 
take on reparative action. At times the lesions break down 
into ulcers, which may be quite deep ; these are not infre- 
quently met with on the fingers and toes, especially on the 
joints. 

The course of the eruption varies with the general con- 
dition of the patient ; new bulla? are apt to come out from 
day to day, while the older ones become pustular, rupture, 
and are succeeded by excoriated, unhealthy-looking sur- 
faces. Other cutaneous lesions, as moist papules and patches, 
about the genitalia and other regions, mucous patches in 
the mouth, fissures, and discolorations of the skin are usu- 
ally at the same time present; in some cases, however, the 
bulla? are the only skin lesions encountered. Other symp- 
toms of the disease may almost always be found. The 
bullous syphiloderm in the infant is a grave manifestation. 
The little patient very rarely lives. 

Pathology. — The anatomy of the syphilodermata has re- 
ceived careful investigation by Auspitz,* Neumann, f Biesia- 
deckij and Kaposi. § The typical syphilitic deposit, as 

*Mediz. Jahrbuch. II. Bd., 1864, Wien. "Ueber die Zelleninfiltration 
der Lederhaut bei Lupus, Sypbilis und Scrofulose." 

f Lehrbuch der Hautkrankheiten, p. 448. Wien, 1873. 

$ Beitrage zur physiologischen und pathologischen Anatomie der Haut. 
Sitz. d. mathem. naturw. CI., LVI. Bd. II. Abth. Wien, 1867. 

I Die Syphilis der Haut und der angrenzenden Schleimhaute. Wien, 
1874-75. 



474 NEW GROWTHS. 

encountered in the papule and in the tubercle, is a new 
growth, consisting of a small round cell infiltration, resem- 
bling that of lupus vulgaris. The earliest manifestation of 
syphilis upon the skin, the erythematous syphiloderm, is 
characterized by hyperemia with incipient proliferation of 
connective-tissue cells. The process in this stage does not 
show the specific cell infiltration, this latter first appearing 
with the papule. The capillaries are chiefly involved in the 
production of the macule, a proliferation of connective-tissue 
corpuscles taking place along the walls of the vessels. These 
cells are found to be most numerous in the apices of the 
papillae. 

The papule presents a marked deposition of the syphilitic 
material. As seen in the flat papule it has its seat in the 
mucous layer of the epidermis, papillary layer of the corium, 
and in the body of the corium extending down as far as the 
subcutaneous connective tissue. The extent and depth of 
the infiltration vary with the size of the papule. The infil- 
tration is circumscribed and sharply defined both laterally 
and from the tissues beneath. It is made up of a more or 
less solid mass of disseminated, numerous, small, round cells, 
which vary considerably in size and in other characteristics. 
They show no regularity of distribution, but appear for the 
most part closely packed together, here and there, within the 
meshes of the connective tissue. In some cases the cells are 
so numerous as "almost completely to obliterate all signs of 
the normal structures. In the process of absorption, which 
takes place as the papule is about disappearing, the central 
portion is first absorbed; the papule in this stage thus as- 
sumes a somewhat cup-shaped or scooped form. 

According to Kaposi, in the moist papule, or flat condy- 
loma, there is the same infiltration occupying the same 
structures and extending itself occasionally into the subcu- 
taneous layers. It is likewise sharply defined as to outline. 
The papillae here are very decidedly enlarged, swollen, 
and lengthened into finger-like prolongations, and at times 
formed into two or more club-shaped extremities. The 
mucous layer is also highly developed and much thickened. 

The pustule is, like the papule, also well defined, the 



SYPHILODERMA. 475 

deposit occupying the corium, and, in some instances, the 
subcutaneous connective tissue. According to the size, char- 
acter, and stage of the pustule, will the appearances of the 
infiltration be somewhat different. As stated by Kaposi the 
essential features of the pustule consist in the presence of 
"dimly-contoured, highly granular, cloudy, nucleated (pus) 
cells and free nuclei within the uppermost layer of the corium, 
papillary layer, and rete, seated in a succulent, large-meshed, 
serum-saturated tissue or even in open spaces, covered with 
epidermis (the roof of the pustule)." 

The tubercle and gumma present the same characters as 
the papule, the infiltration extending itself, however, more 
widely and deeper into the cutaneous tissues. The elements 
concerned are the same as in the papule. The extent to 
which the formation is circumscribed, and the depth of the 
infiltration, will of course depend upon the size and form of 
the growth. The deposit ultimately disappears either by 
absorption or by ulceration. 

Treatment. — The treatment of the syphilodermata is that 
of syphilis, the manifestations upon the skin being but one 
group of the many symptoms which take place in the evolu- 
tion of the disease. To enter at length upon the treatment of 
syphilis would carry the chapter beyond the limits assigned 
to it. For a complete exposition, therefore, of this subject 
I must refer the reader to the admirable works of Fouruier,* 
Bumstead,f and Van Buren and Keyes.J I shall, however, en- 
deavor to point out the method and indications for treatment. 

Constitutional Treatment. — In entering upon the treat- 
ment of syphilis, the importance of a systematic course of 
medicine, the length of time required to bring about the 
best results, the nature of the disease, the tendency to re- 
lapses, and the advantages of prolonged treatment, should 
all be clearly stated to the patient. 

It is, in the first place, a matter of considerable moment 



* Lecons sur la Syphilis etudiee plus particulierement chez la Femrue. 
Paris, 1873. 

f The Pathology and Treatment of Venereal Diseases. Philadelphia, 1870. 

j A Practical Treatise on the Surgical Diseases of the Genito-Urinary 
Organs, including Syphilis. New York, 1874. 



476 NEW GROWTHS. 

that the patient be brought under the most favorable hygienic 
influences. The general health is to be carefully looked after 
throughout the entire course of treatment. The benefits to 
be derived from leading a regular life should be impressed 
upon the individual. The mind should not be suffered to 
dwell upon the disease. In the case of men, the use of 
tobacco and spirituous drinks should be interdicted, or at 
least they should be made use of only with the consent of 
the physician. Fresh air, sufficient exercise, relaxation from 
business, and healthy out-door amusements are to be sought 
for. Attention to cleanliness is to be enjoined. Baths, in 
the form either of the cold douche or of the vapor, are useful, 
and may be taken as the case may require. The vapor bath, 
indulged in not too frequently, is often a decided adjuvant in 
the treatment. 

The diet should be directed by the physician ; it should, as 
a rule, be generous, and should consist of the most nourish- 
ing articles, as meat, eggs, milk, and wine or malt liquor, as 
may seem necessary. The bowels demand attention; if con- 
stipated they should be kept open by means of one or another 
of the natural saline aperient waters or by small doses of 
aloes. The condition of the various secretions of the econ- 
omy should be inquired into, and, if disordered, corrected by 
appropriate remedies. In a word, everything should be done 
to assist nature in coping with the disease. 

The two specific remedies employed in the treatment of 
syphilis are mercury and iodide of potassium. They are the 
only two remedies that have a direct action on the disease. 
Their value is inestimable. Of the two, mercury is by far 
the more valuable. They are employed either alone or in 
combination. The indications for the use of one or the other, 
or for their conjoint use, are found in connection with the age 
of the disease, the character of the eruption, and the general 
condition of the patient. I would here state that mercury 
is a safe remedy; employed judiciously, under the advice 
of one familiar with its action, it may be used without fear 
of evil consequences. It may be administered in small doses 
for one or two years without injury to the general health. 
In this connection it need scarcely be remarked that when 



SYPHILODERMA. 477 

given for a long period continuously it is essential that the 
dose be small, and that salivation be at no time induced. 

Mercury may be introduced into the system in a variety 
of ways. The usual method, and without doubt the best for 
the majority of cases, is by the mouth. Patients vastly pre- 
fer to be treated by this plan, for obvious reasons; it is, more- 
over, the most practical method of treatment. A number of 
the preparations of mercury are made use of; blue mass, 
calomel, corrosive sublimate, gray powder, the protiodide, 
the biniodide, and the bicyanide, all enjoy reputation, and 
are employed to fulfil certain indications. Their manner of 
affecting the system is somewhat different, and hence the 
selection of one or another will depend upon the case to 
be treated. The most active and energetic preparations are 
the mild chloride and the protiodide. The system may be 
brought under the influence of the mineral more rapidly by 
calomel than by any other preparation; hence it is valuable 
where an immediate effect is demanded, as, for example, 
where there is grave iritis or serious throat trouble, threat- 
ening destruction to the parts. It may be given in one or 
two grain doses with a quarter or third of a grain of opium, 
three or four times daily. A more rapid effect even is to be 
obtained from oft repeated minute, fractional grain doses, as 
an eighth or a twelfth of a grain every hour, continued for a 
few days. The system is usually brought under the influence 
of the mineral by this latter method in two or three days. 

The protiodide is the remedy in most general use at the 
present day, and for the majority of cases is to be preferred 
to other preparations. It is given in quarter, third, or half 
grain doses, three times daily, usually with opium, extract of 
lactucarium or hyoscyamus, and in pill form, as, for example, 
according to the following formula : 

R Hydrargyri Iodidi Viridi, gr. x; 

Pulv. Opii, gr. vii. 
M. Ft. in pil. no. xxx. div. 
Sig. One pill three times daily after meals. 

The protiodide is an active preparation. At times it is 
irritating. Not infrequently, when taken for some time, it 
induces gastric and intestinal derangement, griping pains, 



478 NEW GROWTHS. 

and diarrhoea. These symptoms, however, are counteracted 
in a great measure by the simultaneous use of opium or 
hyoscyamus, as suggested. 

Blue mass and gray powder are both mild and compara- 
tively slow in their action ; they are, nevertheless, valuable 
preparations. They are among the least irritating of the 
mercurials ; this is especially true of the latter. Gray powder 
is the most desirable of all the mercurials for infants and 
children. Bumstead speaks well of the blue pill with iron 
and opium in the early syphilodermata, as in the following 
prescription : 

R Pilulse Hydrargyri, ^ii ; 

Ferri Sulphatis Exsiccati, ^i ; 

Extracti Opii, gr. v. 
M. Ft. in pil. no. xx. div. 
Sig. One pill three times daily after meals. 

According to the same author quinine may be very advan- 
tageously combined with gray powder, rendering the mer- 
cury less liable to salivate. The dose of the gray powder is 
about two grains three times daily. For infants the dose is 
from a half grain to a grain, twice daily ; it may be given 
with sugar. 

The corrosive chloride acts slowly, and, as a rule, is well 
borne, manifesting comparatively little disposition to salivate; 
it is, indeed, perhaps the least active of all the preparations. 
When taken for a time it tends to produce pains in the 
stomach and bowels. It is seldom employed in early syph- 
ilis ; it is more often used for the later manifestations. Where 
iron is called for, it may be advantageously combined with 
the tincture of the chloride of iron. It may be prescribed 
with water, alcoholic mixtures, vegetable tinctures or syrups, 
or it may be given in pill form. The dose is about one-six- 
teenth of a grain, three times daily. It should be taken after 
meals. The bicyanide of mercury, in the dose of from 
one-twentieth to one-sixteenth of a grain, in pill form with 
gentian, quinine*or opium, is highly esteemed by Fox,* who 
prefers it to the other preparations. 

* Loc. cit., p. 306. 



STPHILODERMA. 479 

Mercury is also introduced into the system by inunction. 
It is a valuable method of treatment, and is frequently most 
advantageously employed. It acts rapidly, and when pushed 
brings the system under the influence of the remedy in a 
short time. It is therefore useful in those cases where 
a speedy effect is desired ; in old cases of syphilis ; and 
where mercury is not well borne by the stomach. It consti- 
tutes the best method of treating the disease in the infant. 
The two preparations employed are mercurial ointment, 
and oleate of mercury (as suggested by Berkeley Hill) 
from five to twenty per cent, strength. To avoid irritation 
of the skin, the frictions are made upon various regions. 
The arms, axillae, thighs, abdomen, chest, and back, are 
the localities to be selected for the rubbings. Beginning: 
with one or another of these regions, for example, the 
arms, the other parts are in turn taken up, when the parts 
that were first rubbed are again subjected to the process. 
The frictions are performed slowly, with the hand, the 
operation requiring from fifteen to thirty minutes or until 
the preparation used has been quite dissipated. Ordinarily 
they are made once in the twenty-four hours, the substance 
employed being allowed to remain on the skin for one or two 
days before being washed oft* preparatory to another rubbing. 
The skin should never be suffered to become irritated ; if such 
be the tendency, new localities must be selected, a weaker 
ointment employed, or the treatment by this method sus- 
pended. The requisite quantity for each friction is from a 
half to one drachm of the officinal mercurial ointment, and 
about a drachm of the ten or fifteen per cent, oleate of 
mercury. For infants the mercurial ointment should be 
weakened by mixing with one, two or more parts of lard. 
Salivation is to be guarded against. 

Perhaps the chief objection to inunction is its uncleanli- 
ness; patients not infrequently object to its use on account 
of the exposure to which the soiling of the underclothing 
subjects them. Nevertheless its value in certain cases is not 
to be lost sight of. 

Mercury is also administered subcutaneously, by means of 
the hypodermic syringe and corrosive sublimate dissolved in 



480 NEW GROWTHS. 

water, with morphia. Lewin* employs, for each injection, a 
fluid consisting of about one-eighth of a grain of corrosive 
sublimate dissolved in fifteen drops of water with one-twelfth 
of a grain of morphia. The region selected for the puncture 
is usually the back. The operation is repeated once or twice 
daily. Although experience has shown that this method may 
be employed in certain cases with good result, it has many 
disadvantages, chief among which are that it calls for much 
time on the part of both physician and patient; that it is 
painful ; and that it is followed not infrequently by subcuta- 
neous abscesses, and by salivation. Patients as a rule object 
seriously to its use. 

The mercurial vapor bath is yet another method, and a 
valuable one, although, on account of the special appliances 
and the time required, it is not adapted for general use. 
Parker,f Lee,J and Milton § are all warm defenders of this 
mode of administering the remedy, to whose writings I must 
refer the reader for a description of the necessary apparatus. 

For infants the corrosive sublimate bath is very service- 
able; it is prepared in the strength of from ten to twenty 
grains to an infant's bathtubful of warm water. The little 
patient is allowed to remain in the bath for twenty minutes 
once daily or every other day. 

The selection of one or another of the methods mentioned 
for administering mercury must depend upon the require- 
ments of the case under consideration, as well as upon other 
circumstances. The age of the patient is to be taken into 
account; in infants and young children, for example, the best 
results are to be obtained from inunction and the mercurial 
water bath. The general health, whether stout or weakly and 
debilitated; the condition of the alimentary canal; and the 
occupation of the patient, are to be borne in mind. The 

* Die Behandlung der Syphilis mit subcutaner Sublimat-Injection. Berlin, 
1869. For further information, see interesting papers by Wigglesworth, Bos- 
ton Med. and Surg. Jour., Aug. 26, 1869 ; and Taylor, New York Med. G-az., 
May 13, 1871. 

j The Modern Treatment of Syphilitic Diseases. London, 1871. 

% Lectures on Syphilitic and Vaccino-Syphilitic Inoculations. London, 
1863. 

\ The Treatment of Syphilis. London, 1875. 



SYPHILODERMA. 481 

rapidity with which it is considered to be desirable to bring 
the system under the influence of the remedy; whether the 
patient is to be under continuous observation; to be seen 
only at intervals or irregularly ; must decide in favor of one 
or another method. 

Throughout the treatment it is of importance to look to 
the health of the patient. To secure good results from mer- 
cury, it is essential that a high standard of general health 
be maintained daring the period of its employment. In 
the majority of cases, therefore, tonics are called for, the 
preparations of iron, quinine, gentian, and like remedies, 
all being valuable adjuvants in the treatment. They may be 
combined with the mercurial, as, for example, in the formula 
given, or may be prescribed separately. Cod-liver oil will 
also not infrequently be found a useful remedy, especially 
in the later manifestations accompanied with debility. 

In this connection the various vegetable infusions, decoc- 
tions and fluid extracts, as those of sarsaparilla, mezereon, 
guaiacum, dulcamara and stillingia, may be mentioned. They 
act as diaphoretics, cathartics, and tonics. Their chief value 
is in syphilis of long standing, in severe and obstinate cases, 
and in subjects broken down and debilitated by the abuse of 
mercury or from other causes. The general condition not 
infrequently improves markedly under their continued use. 
They are to be viewed as alteratives and tonics. They may 
be given alone, or conjointly with mercury or iodide of po- 
tassium. The most efficacious preparations are Zittmann's 
decoction and the compound decoction of sarsaparilla. 

Opium remains to be referred to as a remedy. Great 
benefit in certain cases is to be derived from its use. It 
is particularly valuable in the treatment of the ulcerative 
lesions. The progress of destructive ulcerations may very 
often be arrested by opium after all other means have failed. 
It may be prescribed in doses varying from a half grain to 
two grains, three times daily, or in the case of the extract of 
opium, half the quantity. 

The mineral acids, especially nitric acid, may at times 

be prescribed with advantage in the later stages of the 

disease. 

31 



482 NEW GROWTHS. 

The length of time which mercury is to be employed must 
rest with the case under consideration ; no positive rule can 
be laid down. I would, however, remark that in the vast 
majority of cases the remedy is continued for much too short 
a time. Were its use continued for a longer period, perhaps 
in smaller doses than is customary, there would, without 
doubt, be far fewer relapses. Unless contra-indicated by 
some of the ill effects to be referred to, it may in all cases be 
given with benefit continuously not only until the disappear- 
ance of the symptoms but for some time afterwards. During 
its administration symptoms of constitutional disturbance, 
as ptyalism, and gastric and intestinal derangement, are to 
be watched for; upon their appearance the dose is to be 
reduced, or the treatment discontinued for the time. The 
period at which these symptoms may be looked for varies 
extremely ; in susceptible cases the system may be affected 
in a few days ; in another case weeks may be required to 
bring about this condition. 

For early syphilis I am in favor of giving mercury in small 
doses, and of continuing its use for a long period, inter- 
mitting its administration from time to time. To obtain the 
best results, it should be prescribed according to the follow- 
ing plan, the advantages of which have been ably set forth 
by Fournier.* It should be given until all the symptoms have 
disappeared, and for three or four weeks longer, in all prob- 
ably two months from the commencement of the treatment, 
when it is to be interrupted for about a month. It is now 
to be recommenced and continued with for another course 
of two months, when all treatment may be stopped for two 
months. At the expiration of this period of rest, a third 
course is to be undertaken, lasting from six to eight weeks, 
to be followed as before by a two months' respite. The 
whole course of treatment should extend over a period of 
at least two years. During the second year, it is, in the 
majority of cases, proper to combine iodide of potassium 
with the mercury. 



* Loc. cit., p. 1080. See a translation by Dr. K. W. Taylor, in the N. Y. 
Med. Jour., vol. xvi. 



SYPHILODERMA. 483 

Other methods of employing mercury are also recom- 
mended by eminent syphilologists. Van Buren and Keyes 
advocate unhesitatingly the practice of giving the remedy 
unremittingly, in small doses, not sufficient to affect the sys- 
tem unfavorably in any way, for a period of not less than 
two years, making use of the iodide of potassium when neces- 
sary. Still another plan is urged ; that of giving full doses 
of the mineral in rapid succession until slight salivation is 
induced, when it is withheld for a while. The course is 
repeated as many times as the case may seem to require. 
The method has been prominently brought forward by Hunt,* 
of London. 

The so-called bad or injurious effects of mercury are in all 
cases to be avoided. They comprise ptyalism, tenderness of 
the gums, fetid breath, metallic taste, stomatitis, diarrhoea 
and griping pains, and, at times, depression of spirits, loss of 
appetite, and general malaise. With the manifestation of 
these symptoms, the dose is to be at once reduced or the 
treatment suspended, as the case may appear to demand. 
Salivation is to be treated by chlorate of potassium, in the 
form of a gargle, a drachm to four ounces of water, and by 
internal administration, one or two drachms in solution in 
the course of the twenty-four hours. 

Iodide of potassium remains to be referred to. It is a 
most valuable remedy. It finds its chief use in the later 
eruptions, as, for example, those which occur in the second, 
third and subsequent years. The older the manifestation 
the more apt is the result to be satisfactory. It is prescribed 
either with mercury or alone. Decidedly more lasting effects 
are to be derived from its employment in combination with 
mercury than when used alone. It is administered either in 
solution, with wine of iron or with one of the palatable 
syrups, as syrup of orange peel, ginger or sarsaparilla, 
largely diluted with water, or in the form of the compressed 
pill; the former mode is preferable, for the pill when given 
in over five-grain strength is apt to produce gastric dis- 



* On Syphilitic Eruptions, etc., with especial reference to the Use and 
Abuse of Mercury. London, 1854. 



484 NEW GROWTHS. 

order. According to Bumstead and others, the action of 
the iodide of potassium is increased by combination with 
chloride of ammonium (equal parts). Carbonate of ammo- 
nium is also said to render the iodide more efficient as well 
as more agreeable. The dose, when used alone, varies from 
five to thirty or forty grains three times daily ; the average 
dose is ten grains. When taken for the first time, it is well 
to begin with smaller doses, from two to five grains, gradually 
increasing the amount. It should be administered about an 
hour after meals. 

The treatment by iodide of potassium and mercury com- 
bined, the so-called " mixed treatment," is exceedingly val- 
uable in the second and later years of the disease. The two 
remedies are usually mixed in the same prescription. They 
may also be given separately and alternately at different 
hours of the day. The iodide may also be administered 
internally in connection with mercurial inunction, a plan 
useful in debilitated subjects, and in inveterate cases, where 
the stomach is apt to become deranged under the continued 
use of mercury. The corrosive chloride and the biniodide 
are the two mercurials ordinarily combined with the iodide 
of potassium. They are prescribed in from one-thirty-second 
to one-twelfth of a grain, with from two to fi.ve or more grains 
-of the iodide of potassium, for each dose, as, for example, 
in the following formula containing the biniodide : 

R Hydrargyri Iodidi Kubri, gr. ii ; 
Potassii Iodidi, giiss ; 
Syrupi Zingiberis, f^ii; 
Aquae, f^ii. 
M. — Sig. One teaspoonful three times daily, after meals, 
with a wineglassful of water. 

The doses of both mercury and iodide of potassium may 
be increased or diminished to suit the demands of the case. 

The length of time which the iodide of potassium, either 
alone or with mercury, is to be employed, must vary with the 
case ; it may, however, be stated that it should be continued 
for weeks or months after the disappearance of the lesions. 

The unpleasant effects of iodide of potassium consist of 
iodisra, irritation of the mucous membranes, salivation, and 



SYPHILODERMA. 485 

a peculiar eruption. Iodism is characterized by fulness in 
the head, headache, nervous symptoms, ringing in the ears, 
and general depression ; the condition is only occasionally 
met with. Of much more frequent occurrence than iodism 
is irritation of the mucous membranes, taking the form of 
coryza, with running at the nose, swelling of the eyelids and 
watering of the eyes, redness of the conjunctivae, and, at 
times, pain in the frontal sinuses. Increased salivary flow 
may also take place, although it occurs rarely in a marked 
degree. The iodide at times gives rise to eruptions upon the 
skin which assume the form of erythema, acne, furuncular 
inflammations, pustules, and blebs. 

Iodine, iodide of sodium, and iodide of ammonium, are 
also at times employed with benefit. They are, however, 
much inferior to the iodide of potassium. 

Local Treatment. — The local treatment of the syphilo- 
dermata consists in the judicious employment of baths, 
lotions, and topical applications in the form of liquids, 
powders, or ointments. The baths are variously prepared 
with starch, alkalies, and the mercurials. 

The erythematous syphiloderm does not require local 
treatment. The papular manifestation may be much im- 
proved by the occasional use of the mercurial vapor bath, 
or the corrosive sublimate bath, one to three drachms to 
thirty gallons of water. The various mercurial ointments 
are of decided service in removing papules, and are often 
applied to these lesions when they affect the face and neck. 
Ammoniated mercury, a half drachm to the ounce of oint- 
ment; and ointment of the nitrate of mercury, a drachm 
to the ounce of ointment, are the most useful. Oleate of 
mercury, five per cent, strength, may also be employed with 
benefit. 

Moist papules in all cases require immediate attention. 
Strict regard to cleanliness is of the first importance; the 
lesions should be washed with water and castile soap several 
times in the course of the day, and the parts, where the sur- 
faces oppose each other, kept separated by lint. In addition 
to the cleansing, they may be bathed with dilute chlorinated 



486 NEW GROWTHS. 

soda solution, one part to two or four of water, twice daily, 
after which powdered starch, oxide of zinc or calomel, may 
be dusted upon them. They may also at times be advanta- 
geously painted with a solution of nitrate of silver. 

The papulo-squamous lesions may be treated with the sim- 
ple or mercurial vapor bath, employed once or twice a week. 
In the localized conditions, as upon the palms and soles, 
tarry ointments and the various mercurial ointments may be 
applied with benefit. 

In the ulcerative affections the crusts are to be removed by 
poultices or other means, and the lesions dressed with one or 
another of the mercurial ointments already referred to, or 
with the " emplastrum de Vigo cum mercurio." The tuber- 
cular formations call for the same local remedies as the large 
papules. 

CARCINOMA CUTIS. 

Under this head are found the several varieties of cancer 
which manifest themselves in connection with the integu- 
ment, both as primary and secondary affections. Of the 
primary cancers of the skin, the most common form is that 
to which the term epithelial cancer is given, and it is this 
which more especially concerns the dermatologist. 

The fibrous and medullary cancers, the melanotic and 
colloid forms, whether diffused or circumscribed, fungoid or 
tuberous, rarely attack the skin primarily, hence fall rather 
into the domain of surgery. 

EPITHELIOMA. 

Syn. Epithelial Cancer ; Cancroid; Carcinoma Epitheliale ; Germ., Epithe- 
lialkrebs; Fr., Epithelioma; Cancro'ide. 

Symptoms. — Epithelial cancer of the skin manifests itself 
clinically in three forms, which are very properly designated 
as the superficial, deep-seated, and papillary varieties. 

Superficial Variety (known also as the " flat" variety). — 
The disease here usually makes its appearance as one, or, at 
times, several grouped small yellowish or reddish papules or 
elevations, having their seat in the superficial layers of the 
skin. They may start from a sebaceous gland, wart or other 



EPITHELIOMA. 487 

growth, or in the form of a flat infiltration. Sooner or later, 
usually in the course of years, the tubercle, wart or infiltration 
shows a disposition to fissure or to excoriate, and to be covered 
with a slight brownish or yellowish crust, under which may 
be observed a scanty, watery or viscid secretion. The course 
of the disease is commonly very slow, years not infrequently 
elapsing before much progress takes place. In time, how- 
ever, the tubercles or deposits increase in size, or new ones 
appear, and finally break down into superficial ulcers of 
various size and appearance. In size the ulcer may be no 
larger than a split pea when first seen, but it inclines to 
become larger by degrees, and may ultimately assume the di- 
mensions of a large coin or the palm of the hand. In shape 
it is usually roundish; at times it is irregular in outline. Its 
edges are abrupt and sharply defined against the sound skin. 
They are not raised or everted, and do not appear reddened 
or infiltrated, although they may be quite indurated. The 
base of the ulcer is reddish in color; secretes a scanty, viscid, 
yellowish fluid; disposes to bleed; and has an uneven sur- 
face, which is apt to be hard. The amount of pain present 
varies ; it is not usually marked until the ulcer has assumed 
considerable size. 

The further changes which occur may vary. At times 
the ulcer having assumed a certain size ceases to grow 
larger. In other cases it extends itself and attacks the deeper 
structures, and passes into the infiltrating, or deep-seated, 
variety. It may continue for years as an apparently local 
affection, the patient enjoying excellent general health. The 
lymphatic glands are not enlarged or at all involved. 

The disease which was for a long period designated ro- 
dent ulcer, and considered as distinct from epithelioma, is 
now known to be in most, if not all, instances, this form of 
epithelial cancer. Warren, of Boston, has recently furnished 
additional evidence in a clear and satisfactory manner.* 

Deep-seated Variety (termed also the "infiltrating" va 
riety). — This usually commences by the formation of a 



* The Anatomy and Development of Kodent Ulcer. A Boylston Medical 
Prize Essay for 1872, by J. Collins Warren, M.D. 



488 NEW GROWTHS. 

roundish, often conical, tubercle about the size of a split pea, 
having its seat in the skin. It may also start in the form of 
a wart or papilloma, as in the case of the superficial variety. 
One or several of these tubercular formations may be present 
at first; later they are apt to run together and to form a 
nodular mass, the size of a nut or larger. The growth is 
generally raised ; is firmly and deeply seated in the tissues ; 
is reddish or purplish in color; is surrounded with an areola; 
is hard to the touch ; has an uneven surface ; and presents 
signs of extensive infiltration both in the deeper structures 
and around its periphery. Instead of being prominently 
elevated, it may extend itself on all sides in the form of an 
outspread, flat deposit, but slightly raised above the sur- 
rounding skin. 

In a shorter or longer time, in the course of months or 
years, according to the malignancy of the case, ulceration 
takes place, which begins either on the surface or in the 
interior of the growth. The tumor finally breaks up, dis- 
integrates, and an ulcer varying in size, shape and general 
characters results. The ulcer, when of any size, presents 
a deep excavation in the tissues ; is roundish or irregular in 
shape ; has an uneven, reddish or brownish colored base, 
with sloping walls ; secretes an offensive, pale-yellowish, 
viscid, stringy fluid ; bleeds readily upon being manipu- 
lated ; and possesses raised, markedly everted, hard, puffy, 
purplish edges. Infiltration is observed to extend itself for 
some distance around the cavity, as shown by the induration 
of the tissues and the redness of the surface. The destruc- 
tive process now usually progresses rapidly, all of the tissues 
of the region becoming invaded and breaking down, until 
finally an ulcer the size of the palm or larger is produced. 
The disease is now often very painful, the sharp, lancinating 
pains, which are commonly present to a greater or less ex- 
tent throughout the disease, becoming almost unendurable. 
The lymphatic glands enlarge, and at times break down. 
The patient suffers extremely, and sooner or later succumbs 
through exhaustion. 

The course of this variety of epithelioma varies; it may 
be either slow, or, on the other hand, exceedingly rapid. I 






EPITHELIOMA. 489 

recall the case of a gentleman, sixty-five years of age, who 
was under my care, from the beginning to the end, in whom 
the disease ran its malignant and fatal course in about one 
year, in spite of the most active treatment. Eelapses are 
common. 

Papillary Variety.— In the place of an infiltration the 
lesion may be a papillary growth or cauliflower-like excres- 
cence. Formations of this character vary greatly as to size, 
shape, and outline. They may begin as wart-like growths 
the size of a split pea or finger-nail, possessing all the features 
of a common wart; or they may appear as larger, coin or palm- 
sized, raised, lobulated, spongy, markedly papillary forma- 
tions. The appearances vary according to the stage of the 
process. The surface may be either dry or moist. At times 
it is covered with a thin layer of horny, wart-like, yellowish 
epidermis; in other cases the epidermis is in a state of macer- 
ation, and is seen as a cheesy substance. Not infrequently 
the surface of the growth gives out a viscid or thick secretion, 
mingled with blood and whitish cheesy or sebaceous matter, 
like that obtained from comedones and sebaceous cysts. The 
granulations may be exuberant, fleshy, and uneven, or they 
may be stunted and flat, inclining to spread out rather than to 
grow in height. Fissures are usually present, which secrete 
a semi-fluid, offensive product, composed of epithelial and 
sebaceous matter, which with blood is apt to form into 
a brownish, adherent crust. In these cases the growth re- 
sembles the venereal acuminated wart, or condyloma. In 
time the formation, either in places or over its whole sur- 
face, shows signs of disintegration ; ultimately an irregularly- 
shaped ulcer, with more or less extensive granulations, forms, 
which runs the course of other epitheliomatous ulcers. This 
variety of epithelial cancer may start as a papillary growth, 
or it may proceed from a previously-existing superficial or 
deep-seated infiltration. 

Epithelioma has its seats of predilection. Its most com- 
mon seat is upon the face. It is encountered upon the lips, 
more often upon the lower lip, where it appears usually in 
the form either of the superficial or deep-seated variety. It 
is also of common occurrence about the inside of the lip, 



490 NEW GROWTHS. 

the tongue, and the mouth. The nose is also frequently 
attacked, the disease very often beginning upon the side of 
the bridge. The cheeks, temples, forehead, eyelids, are also 
localities in which the affection is not infrequently seen. The 
face is much more prone to be invaded by the superficial than 
by the deep-seated variety. The genitalia, especially the 
penis and scrotum in the male, and the labia in the female, 
are not uncommon seats of the disease; upon the glans 
penis it is apt to show itself as a papillary growth; upon the 
scrotum as the superficial form ; upon the labia either as the 
superficial or deep-seated variety. Other localities of the 
body are also liable to epithelial cancer; it may occur upon 
the trunk, and, more rarely, upon the lower extremities. 

Epitheliomatous growths are usually single in number; it 
rarely happens that two are met with upon the same indi- 
vidual. 

Etiology. — The causes of epithelial cancer are obscure. In 
many instances no cause whatever can be given. The dis- 
ease is encountered much more frequently in the male than 
in the female. Thiersch found that out of 102 cases col- 
lected by him, 80 occurred in men and 22 in women.* 
Paget's experience is similar; in 105 cases, affecting regions 
common to both sexes, 86 were in males and 19 in females.f 

Epithelioma rarely shows itself before middle life, com- 
monly not before the age of forty-five or fifty. It may, how- 
ever, make its appearance earlier, and a few cases are on 
record where it occurred as early as childhood. It is apt 
to have its starting-point in a locally irritated tissue, as, 
for example, in an excoriation, or about a lip that has been 
irritated by the use of tobacco. Warts of all kinds are the 
seat at which epithelioma very commonly first makes its 
appearance. Nsevi, both pigmentary and vascular, are also 
structures in which it is well known the disease often com- 
mences. Occasionally epithelial cancer appears to be hered- 
itary; in the vast majority of instances, however, no such 
disease can be ascertained to have existed in parents. 

* Der Epithelialkrebs namentlich der Haut, p. 305. Leipzig, 1865. 
f Lectures on Surgical Pathology. 3d edition, p. 733. 



EPITHELIOMA. 491 

Pathology. — The anatomy of epithelial cancer of the skin 
varies somewhat with the form of the disease under con- 
sideration, and with the stage of the process. According 
as the growth happens to be superficial, papillary or deep- 
seated, will there be more or less difference in the anatomical 
arrangement and distribution of the pathological formation. 
As a type of the disease, that which occurs about the lip may 
be taken. If the growth be incised with a knife, the cut 
surface is seen with the naked eye to be of a grayish, yel- 
lowish or pale-red color, and to be marked here and there, 
particularly near the surface, with numerous minute grayish 
or yellowish points, rounded accumulations, and irregular 
bands or streaks, which usually occupy a considerable por- 
tion of the structure ; these formations are the epithelial 
processes and globes, to be referred to. Upon pressure the 
cut surface of an epithelioma yields a more or less scanty, 
watery or viscid, yellowish fluid, together with a whitish or 
yellowish, firm or soft, cheesy, more or less granular mate- 
rial, similar to that of the secretion of comedones. This 
substance may usually be squeezed out of the growth, when 
it appears in the form of small, rounded, comedo-like plugs, 
variable as to number and size. The character of the pro- 
duct obtained from a section will vary considerably with 
the variety and seat of the disease, as well as with its age; 
thus it may be dry, friable, and firm, or soft and semi-fluid. 
The amount of vascularity also varies. 

In microscopic structure, epithelioma is made up of epithe- 
lial cells, which vary greatly as to size, shape, and arrange- 
ment. The cells range themselves into masses which are 
characterized by growing into and invading other tissues, 
as connective tissue, where they form peculiar structures, 
which assume the shape either of cylindrical processes or 
of rounded, globular bodies. The cells may first be re- 
ferred to. They are of the squamous, or pavement, variety, 
and differ but little from normal epithelium as met with 
upon the skin or mucous membrane of the mouth. They 
present nothing characteristic of epithelioma. They are 
thin, flat, and variously shaped; their form varies with 
their age and with the part of the growth from which they 



492 NEW GROWTHS. 

come. When young, they are rounded; as they grow older 
they become polygonal, mostly irregular and angular in 
outline, and finally caudate or elongated. They contain, 
as a rule, a nucleus, which is usually large and rounded ; 
more rarely they have two nuclei. As they become older 
they lose their nuclei. The cells frequently undergo change 
into fatty degeneration, the nucleus disappearing, and the 
cells showing fine granular dots and oil globules. 

The cells may be arranged either in the form of club- 
shaped, cylindrical or conical processes, or of rounded nests, 
or globes (known also as "concentric globules," " fibrous 
capsules," " laminated capsules," "onion-shaped bodies," 
"epithelial nests," "pearl globules," "epithelial pearls," 
" epithelial globes"). 

The processes referred to consist of the mucous layer of 
the epidermis, projected into the connective tissue in the 
form of long, narrow, finger-shaped growths. The cells are 
usually greatly crowded, so much so as to constitute solid 
masses or plugs of epithelium. They vary as to size, and as 
to the depth to which they penetrate. At times they are so 
large as to be seen in sections with the naked eye, appearing as 
streaks and irregular lines, running from the surface towards 
the centre of the growth. These cylindriform processes are 
not infrequently developed in such numbers as almost to 
obliterate the papillae. In highly developed epitheliomata 
they penetrate in all directions, extend deeply into the con- 
nective tissue, press upon the surrounding structures, and 
finally take more or less complete possession of the whole 
skin. Ultimately they undergo retrograde metamorphosis, 
ending either in fatty or in keratoid or colloid degeneration. 
They either disappear by absorption, or ulceration results 
and they are exfoliated from the surface. 

The epithelial globes are made up of concentrically ar- 
ranged cells, disposed like the coats of an onion. In consist- 
ence they may be solid or soft. The cells composing these 
masses vary; those in the centre are usually small, round, 
and succulent, while those on the periphery are elongated, 
flat, dry, and horny. The globes vary greatly in size ; not 
infrequently they are so large as to be readily seen with the 



EPITHELIOMA. 493 

naked eye. In form they are rounded or oval, and circum- 
scribed. They are found in the cylindriform processes, and 
also in other portions of the growth. They are not, how- 
ever, characteristic of epithelial cancer; they may occur 
wherever epithelium is undergoing proliferation and reten- 
tion, as, for example, in milium and in sebaceous cyst. 

The amount of stroma existing with epithelial cancer 
varies ; it is, however, never a marked element in the anat- 
omy of the disease. It is seen chiefly in the papillary and 
deep-seated varieties. 

Concerning the histogenesis, or the formation and develop- 
ment of epithelial cancer, there can be no doubt that it takes 
its origin from the normal epithelium of the skin, mucous 
membrane or glands. Compared with other varieties of 
carcinoma, epithelioma possesses a decidedly less degree of 
malignancy, and this a relatively local one. 

Diagnosis. — Epithelioma may be confounded with syphilitic 
tubercles and ulcerations, acuminated warts, lupus, and the 
rare affection rhinoscleroma. The papule or ulcer of epithe- 
lial cancer, especially if about the genitalia, may resemble 
the chancre ; attention to the history of the case, the dura- 
tion of the lesion, as well as to other points of diagnostic 
value, will aid in arriving at a correct opinion. The evolu- 
tion of late syphilitic formations is always much more rapid 
than that of cancerous deposits ; only rarely, in malignant 
cases, does epithelioma run a rapid course, one of months. 
The character, moreover, of the ulcerative process due to 
syphilis is very different from that of epithelial cancer. In 
tubercular syphilis two, three or more points of ulceration 
are apt to exist; in cancer usually only one. In syphilis 
the secretion is abundant, yellowish, and creamy; in cancer 
it is scanty, water-colored, streaked with blood, viscid, and 
stringy. The condition of the tissues surrounding the ulcer 
i3 different. In cancer there is more or less induration and 
areolar redness; in syphilis there is none, the deposit ter- 
minating abruptly against the sound skin. In cancer there 
is apt to be pain of a lancinating character; in syphilis the 
ulcer is without pain. 

Inasmuch as many epithelial cancers begin in the form 



494 NEW GROWTHS. 

of warts, papillomata, etc., it is often difficult to decide 
whether the lesion is a simple wart, or is of a cancerous 
nature. The history of the case, the mode of advance, the 
general appearance of the growth, the age of the patient, 
and the course of the disease, must determine its nature. 
Observation of the case for a short time generally enables 
the surgeon to establish the diagnosis beyond doubt. 

Epithelioma may be known from lupus vulgaris by its 
usually attacking the middle-aged and the old ; lupus vul- 
garis commonly first shows itself in the young, often in early 
childhood. Epithelioma is almost invariably a single forma- 
tion ; the deposits of lupus are commonly multiple; lupus, 
moreover, is apt to invade several regions of the body at the 
same time, as, for example, the face and hand. When ulcer- 
ation takes place in lupus, or when it assumes an hyper- 
trophic form, the diagnosis becomes more difficult, the two 
diseases in this case often closely resembling each other; but 
the peculiar, macular and papular deposits of lupus, aggre- 
gated into patches, and having their seat usually around the 
ulcer, will serve to distinguish it from epithelial cancer. 
The discharge from a cancerous ulcer is, moreover, different 
from that of a lupus ulcer; it is scanty, viscid, and pale, 
while that of lupus is quite abundant, yellowish, and puri- 
form. The discharge from the ulcer of epithelioma is usually 
offensive ; that from lupus is, as a rule, not so, notwithstand- 
ing great destruction of the tissues. 

Treatment. — The diagnosis once established, the sooner 
treatment is instituted the better. Internal remedies are of 
no avail. The growth is to be removed, with as much of 
the tissue immediately about it as the case in hand may 
appear to call for. This may be accomplished either by the 
knife or by cauterization. The operation to be preferred will 
depend upon the variety of cancer, whether superficial or 
deep-seated; the extent to which the surrounding tissues 
are affected; and the locality attacked. In some cases the 
knife will prove most serviceable, in others caustics. The 
ultimate result, as regards relapses, will be found about the 
same with either mode of procedure, provided both opera- 
tions are performed with equal skill. Superficial epithe- 



EPITHELIOMA. 495 

liomata are, in the majority of cases, best removed with 
caustic. Among the various remedies, caustic potash, pure 
or weakened, in stick form or in solution, in my opinion, 
occupies the first position. It is effectual, and may be de- 
pended upon. It causes much less pain than other power- 
ful caustics; moreover, the pain does not continue after 
the cauterization, and by means of acids may be almost in- 
stantaneously relieved. The growth should be thoroughly 
cauterized, no part of it being permitted to remain undis- 
turbed. In all cases it is advisable to carry the caustic into 
the border of the sound tissues. As the operation is being 
performed, the operator must determine the extent of the 
disease and the amount of tissue to be acted upon. The 
readiness with which the morbid tissue gives way and is 
destroyed under the caustic, and the resistance experienced 
when in contact with normal structures, will enable the 
surgeon to know when to desist from further cauterization. 
There is usually no hemorrhage. After the operation the 
parts are to be bathed for a few minutes with dilute acetic 
acid, and subsequently dressed with diachylon ointment or 
olive oil and charpie or lint. The dressing may be changed 
once in twelve or twenty-four hours, and the surface of the 
wound carefully washed with soap and water if the secre- 
tion be at all offensive. In the course of a week the eschar 
will have loosened and detached itself, showing a healthy 
granulating wound, which, in cases favorably disposed, will 
heal completely, leaving not infrequently an insignificant 
scar. On the other hand, in cases where the disease is of a 
malignant type, the wound repairs itself in apparently the 
usual healthy manner for the first few weeks, after which 
the reparative process arrives at a stand-still, and the ulcer 
soon breaks down into its former state. This is apt to be 
the course of the deep-seated variety. Potassa cum calce, in 
stick, or in powder form, made into a paste (Vienna paste), 
is also a valuable preparation. It is at times to be preferred 
to the pure caustic potash. 

Other caustics are used for the same purpose. The chlo- 
ride of zinc, either in the form of a paste, with flour, or 
in stick form, enjoys a high reputation for the treatment of 



496 NEW GROWTHS. 

epithelial cancer, especially the superficial variety. It is 
effective, but intensely painful, the pain often remaining 
uncontrollable for several days. I have known it to be so 
severe and so long continued as to greatly prostrate the 
patient. It is, moreover, doubtful whether it possesses the 
advantages over other caustics which have been claimed for 
it. Arsenic, in the form of a paste, may be used with benefit 
in certain cases of the superficial variety, as in the treatment 
of lupus vulgaris. So also nitrate of silver; this substance is 
especially valuable in destroying the early formations of the 
disease, and the small deposits which are apt to occur about 
the margin of superficial ulcers and in relapses. Whatever 
remedy be employed, it should be thoroughly applied ; the 
more thorough the operation, the less likelihood of a relapse. 

On the other hand, there are cases in which it is prefer- 
able to use the knife instead of caustic. The extent of the 
disease, the locality invaded, the previous failure of caustics 
to arrest the process, and other circumstances, not infre- 
quently render extirpation with the knife a better mode of 
procedure. The advisability of one or the other plan of 
operation must be determined by the case in hand. 

The galvanic cautery has been employed with marked 
success in the treatment of epithelioma; it is an effective 
and valuable remedy suitable to many cases.* It is par- 
ticularly adapted to cases where the growth occupies regions 
which could only with difficulty be treated with caustic or 
the knife, as, for example, about the inner canthus of the 
eye. Hebra, Kaposi, and others, speak well of the " scoop" 
or " curette" in the treatment of superficial formations. (See 
the treatment of lupus vulgaris, p. 428.) 

Prognosis. — This is always more or less unfavorable. It 
must vary with each case. The age of the patient; the dura- 
tion of the disease; its course; its locality; whether single 
or multiple ; the variety of the disease, whether superficial 
or deep-seated ; the amount of surrounding infiltration ; the 
presence or absence of glandular involvement; must deter- 
mine the prognosis. 

* See a paper, reporting cases, by Bryant, Lancet, April 4, 1874. 



SARCOMA CUTIS. 497 

The superficial variety may be present, increasing very 
slowly in size, for years without giving rise to serious 
trouble; on the other hand, it may extend quite rapidly 
until an ulcer of considerable size .has formed; in other 
cases it may pass into the deep-seated variety, when the 
prognosis becomes at once more grave. 

The deep-seated variety is always a most serious disease. 
Its course, however, varies greatly. At one time it runs a 
fearfully rapid pace, terminating fatally in one or two years; 
in other cases it extends itself gradually through a long period. 

Relapses frequently take place about the seat of the old 
disease; the patient should always be warned as to the 
possible return of the disease. 

SARCOMA CUTIS. 

Sarcoma of the skin may be described as consisting of 
shot, pea, hazelnut or larger sized, variously shaped, discrete 
tubercles or nodules, pigmented or non-pigmented, having 
their seat in the skin.* They are smooth, firm and elastic, 
and are not markedly painful upon pressure. In color they 
are reddish or brownish-red ; in the pigmented variety they 
are bluish-red or even blackish-red. They may occur either 
singly or in numbers, the latter course being the more usual, 
and may develop upon any portion of the body. They mani- 
fest themselves without regularity of distribution; either in 
the form of groups or as diffused tubercles and tumors. 
According to Kaposi, the multiple pigmented sarcoma, of 
which he describes five cases, always first appears on the 
soles and backs of the feet, and later on the hands, attended 
by a diffuse thickening of the skin. 

The lymphatic vessels and glands are not involved. The 
disease is seen in both men and women, and has been ob- 
served to occur generally towards middle age. It is always 
malignant in character, usually proving fatal in the course 
of a few years. 

* I am indebted to the writings of "Wigglesworth (Archives of Der- 
matology, vol. ii., Xo. II.), Kaposi (Diseases of the Skin, vol. iv.), and 
Kobner (Archiv fur Derm, und Syph., III. Heft, 1869), for my knowledge 
of this disease. 



498 NEW GROWTHS. 

The formation may be either a small or large celled sar- 
coma. Kaposi's cases showed the structure to consist of 
clusters of small round cells in the corium, slight hemor- 
rhages into the corium and papillary layer, and an abundance 
of pigment. In Wigglesworth's case, the disease was found 
to be seated mainly in the cutis, and to consist of large round 
cells with a single granular nucleus, which were relatively 
uniform in size, and considerably larger than white blood 
corpuscles. They were imbedded in a reticulated, delicately 
fibrous stroma, the meshes of which enclosed, as a rule, 
single cells. 

The disease is a rare one, only a few cases being on record. 

NJEVUS VASCULOSIS. 

Syn. Nsevus Vascularis ; Naevus Sanguineus ; Nsevus Flammeus ; Claret 
Stain ; Port Wine Stain. 

Vascular Dsevi are congenital formations, composed chiefly 
of bloodvessels, which have their seat in the skin and sub- 
cutaneous tissues. Their external characters vary ; they may 
be prominent, turgescent, tumor-like, circumscribed growths, 
with an uneven, rugous surface, or they may be flat, non- 
elevated, imperfectly defined, indistinct, smooth patches. In 
form they are roundish or irregularly shaped. They are 
always reddish in color, but vary considerably as to the 
shade. They may be either small or large; sometimes they 
are so extensive as to cover large hand-sized areas. They 
are seldom multiple; Usually only one is present. They are 
encountered upon all parts of the surface, but are commonly 
met with upon the face, neck, trunk, and upper extremities. 
Nsevi vary exceedingly in their course; at one time, having 
attained a certain size, they remain stationary through life, 
while in other cases they retrograde to a variable extent; at 
times, on the other hand, they increase in size. The more 
vascular they are, the more likelihood is there of their be- 
coming larger; ordinarily they remain as permanent deformi- 
ties, tending to decrease as the patient grows older; in some 
cases they have been known to disappear entirely. 

Pathology. — The causes which give rise to nsevi are alto- 
gether unknown. In structure they consist of dilated and 






N^VUS VASCULOSUS. 499 

hypertrophied bloodvessels and capillaries, both arteries and 
veins, which have their seat in the corium and subcutaneous 
tissues. The vessels are to be considered as an abnormal 
growth, being present in unusual size, number, and arrange- 
ment. Sections through naevi show them to be made up of 
vessels of all sizes, which run here and there, without defi- 
nite arrangement, and occupy almost the whole structure ; 
they are held together by connective tissue. Other structures 
common to the normal skin, as hairs and glands, are also 
usually present. In the deeper-seated naevi considerable fat 
tissue at times exists (angioma lipomatodes). 

Treatment. — The treatment to be recommended for the 
removal of naevi, when this is called for, will depend upon 
the region involved, the size, form, and general character 
of the formation under consideration. Various means have 
been suggested ; those which have been attended with most 
success are the following. When the growth is small, the 
size of a split pea, and circumscribed, it may be treated by 
caustic applications, caustic potash being the most service- 
able of this class of remedies. It should be applied in 
solution, the strength varying according to the amount of 
surface to be attacked and the effect produced; the smaller 
the growth the stronger may the solution be made. I am 
in the habit of employing from two to four drachms to the 
ounce of water for small naevi and telangiectases, one, two 
or more applications, at intervals, sufficing to destroy the 
growth. Nitric acid is also successfully employed, especially 
in flat naevi, and, according to Kaposi, may be used even in 
quite large formations. If the growth be of any size, a por- 
tion only should be attacked at one operation. 

Neumann speaks well of an ointment composed of adhesive 
plaster, one drachm, tartar emetic, nine grains, for small, 
tinger-nail sized, raised or flat, circumscribed naevi, especially 
of the scalp. Pustulation and free suppuration take place,, 
followed by a flat, thin, soft scar. The application causes 
but little pain. Kaposi states that success has also resulted 
from painting the naevus with collodion and corrosive sub- 
limate, in the strength of eight grains to the fluidrachm. 
Injections with the sesquichloride of iron, and other like 



500 NEW GROWTHS. 

substances, as formerly practised, are not to be recommended ; 
they are apt to cause extensive sloughing, and, at times, 
hemorrhage. 

Vaccination upon nsevi is at times followed by the satis- 
factory destruction of the growth; the virus should be in- 
serted at various points over the tumor. The results, how- 
ever, are uncertain. 

The treatment of nsevi by the galvanic current, or electrol- 
ysis, constitutes probably the most generally useful method, 
and has been highly recommended in preference to other 
remedies. Numerous instances of its successful employ- 
ment are upon record.* The advantages claimed for it over 
other methods of treatment may be briefly stated as follows : 
the safety of the operation; the absence of hemorrhage ; the 
cessation of pain immediately after operation ; the absence 
of scar in small nsevi; and, Anally, the simplicity, rapidity, 
and effectiveness of the operation. 

Where the tumors are prominent or pedunculated, the liga- 
ture may often be employed with good result, although a scar 
is apt to remain in cases where the growth is of any size. 

TELANGIECTASIS. 

Telangiectases are vascular cutaneous growths which make 
their appearance during the life of the individual. They 
are, therefore, acquired growths in contradistinction to those 
which are congenital and which are called nsevi. They 
occur either in the form of more or less circumscribed for- 
mations or as tortuous lines. They are seen with the naked 
eye to be made up of a network of enlarged capillaries. 

The circumscribed growths vary in size from a pin-head to a 
pea. They are usually on a level with the surrounding skin ; 
not infrequently, however, they are raised. In shape they 
are roundish or irregular with radiating lines. In color they 
vary from bright to dark red. They show themselves singly 
or in numbers; one, two or three may not infrequently be 

* See papers by Carter, Lancet, Jan. 18, 1873 ; Penhall, Lancet, April 11, 
1874; Beard, Phila. Med. Times, Sept. 5, 1874; Knott, Lancet, March 20, 
1875: Duncan, Edin. Med. Jour., Feb., 1876. 



TELANGIECTASIS. 501 

observed here and there over the surface. They may develop 
upon any region ; they are most frequently encountered upon 
the face and neck. 

The lines, appear in the form of an ill-defined patch or 
collection of distended bloodvessels, more or less distinct in 
outline, ramifying over the surface in a tortuous or serpentine 
manner. They are met with upon the face, neck, chest, and 
other regions. 

As a rule, telangiectases do not manifest themselves until 
adult or middle age. They are noted to occur in both sexes. 
They are unattended by pain or inconvenience. Their course 
is slow, enlarging, in the majority of cases, only through a 
period of years; they rarely, however, attain any size. They 
may either remain as permanent growths or they may dis- 
appear spontaneously; having reached a certain size they are 
apt to remain through life. 

Rosacea. — By this term is designated a variety of telan- 
giectasis, characterized by a diffused, more or less general 
dilatation of the cutaneous capillaries of the face. The 
vessels and their ramifications are enlarged and give the 
skin a reddish appearance, marked with lines which are apt 
to be tortuous and irregular in their course. The condition 
may be localized, as is ordinarily the case, as, for example, 
upon the nose ; or it may be generalized, occurring over the 
greater portion of the face. Its common seat is the nose; 
it also manifests itself very frequently upon the cheeks and 
chin. The forehead may also be attacked, either alone or in 
connection with other parts of the face. 

Eosacea may be, and very often is, complicated with acne, 
giving rise to the affection acne rosacea ; or, on the other 
hand, it may occur as the sole disease, without disturbance 
of the sebaceous glands. It is also seen upon the nose in con- 
nection with seborrhcea in chlorotic and ansemic individuals. 

In simple rosacea the skin is usually smooth • in aggravated 
cases it is apt to be rough and uneven, owing to the extreme 
distention of the vessels. "When seborrhcea is present the 
part presents a shining, more or less greasy appearance. 
Upon pressure the redness disappears for the moment, but 
quickly returns. The part is very often warmer than 



502 NEW GROWTHS. 

normal ; in seborrhceic cases, bowever, it is apt to be below 
the normal temperature. The color may be either bright red 
or violaceous, depending upon the duration of the disease, 
the age of the patient, and the cause; it is usually a bright 
red. In rosacea complicated with acne the part usually 
becomes enlarged, and the whole cutaneous tissue hyper- 
trophied. (See Acne Rosacea.) 

The treatment of telangiectasis is that of naevus vasculosus. 

LYMPHANGIOMA CUTIS. 

Under the name of lymphangioma of the skin, Kaposi* 
describes for the first time a disease characterized by the 
formation of numerous, scattered, pea or bean sized, round- 
ish, brownish-red, glistening, smooth, not scaly, flat, slightly 
elevated tubercles, occurring for the most part about the 
trunk. They were observed to become pale on pressure; to 
be firm and elastic to the touch ; to be imbedded in the 
coriurn, but not sharply defined; and to be slightly painful 
on pressure. The appearance of the disease is said to re- 
semble very much a large flat papular syphiloderm. 

The course of the disease in the case referred to was 
extremely slow ; the patient was a woman, thirty-two years 
of age, and some of the tubercles had existed since child- 
hood. 

Microscopical examination of excised tubercles, vertical 
sections, showed the whole coriurn to be perforated by canals, 
which appeared as rounded apertures ; they were made out 
to be immensely developed lymphatic vessels. The growth 
consisted almost entirely of this structure, and appeared to 
have its chief seat in the coriurn. 

The general health of the patient was good. The disease 
evinced no disposition to malignancy. 

* Loc. cit, vol. iii., p. 387. See also Biesiadecki, LTntersuchungen aus dem 
Pathologisch-Anatomischen Institute in Krakau, p. 11. Wien, 1872. 



LYMPHADENOMA CUTIS. 503 



LYMPHADENOMA CUTIS. 

Syn. Lymphadenoma of the Skin; Fr., Lymphadenie Cutanee ; Mycosis 
Fongoide. 

Symptoms. — The disease ha3 been accurately described by 
Gillot* and by Demange.f Three forms of lymphadenoma 
are recognized by these writers, namely: (1) leucocythemic 
lymphadenoma, or leucaemia, characterized by appreciable 
and marked alteration of the blood, and by lesions in the 
spleen ; (2) ganglionic lymphadenoma, or adenoid disease, in 
which the lesions affect chiefly the lymphatic ganglia, and 
sometimes also the spleen ; (3) lymphadenoma of the skin, 
characterized by the production of an abundant adenoid 
tissue, taking place almost exclusively in the skin. These 
forms of the disease may occur together or independently 
of one another. 

Lymphadenoma cutis usually begins insidiously. In the 
various reported cases, the patient enjoyed previous good 
health. At times the first symptoms upon the skin consist 
of patches of dry eczema, which may continue a longer or 
shorter time. Later, tumors, variable as to size and shape, 
situated in and beneath the skin, make their appearance. 
When the disease is fully developed, they vary in size 
from a split pea to a walnut or large tomato ; they are 
more or less elevated above the level of the surrounding 
skin, and very often flat. In shape they are irregularly 
roundish or oval, and often assume the general outline and 
shape of the tomato. To the touch they are hard and some- 
what elastic. They are usually more or less vascular, their 
color being either that of normal skin or reddish and vio- 
laceous. At times they are as red as a ripe tomato. The 
skin over them is smooth, tense, and shining. They are 
painless growths. Sensibility is said to be but slightly im- 
paired. In number they vary ; comparatively few may 



* Etude sur une Affection de la Peau decrite sous le nom de Mycosis Fon- 
goide (Lymphadenie Cutanee). Paris, 1869. 

f Du Mycosis Fongoide ou Lymphadenie Cutanee, Annales de Dermatolo- 
gie et de Syphiligraphie, No. 2, 1873-1874. 



504 NEW GROWTHS. 

exist, or they may be present in large numbers, involving 
all regions of the body, particularly the trunk ; they are 
generally isolated. They increase, as a rule, rapidly in size. 
Having reached certain proportions, they incline either to 
become smaller (and, it is said, to disappear) or, as is usually 
the case, to break down into a state of ulceration. The 
ulceration starts in the centre of the growth, terminating 
sooner or later in a shallow or deep, usually large, freely- 
suppurating, fungoid ulcer, having a reddish or yellowish 
base, with a grayish, viscid secretion. The ulceration is, as a 
rule, very extensive, and is said to be the most characteristic 
feature of the disease. A cachectic condition sets in, followed 
by loss of appetite, diarrhoea, emaciation, a peculiar, pale, 
waxy color of the whole integument, and ultimately death. 
The duration of the disease varies from one to a number of 
years. 

Pathology. — In a case carefully examined by Ranvier,* to 
whom we are chiefly indebted for our knowledge of the nature 
of these formations, the tumors were soft, yielding on section 
a juice exactly like that of cancer or of a lymphatic gland. 
The cells obtained by scraping the surface were like those 
found in connection with irritated lymphatic ganglia ; some 
of the larger ones contained several nuclei ; they were formed 
of a mass of protoplasm without enveloping membrane. In 
non-ulcerated tumors the papillae of the corium were spread 
out, and in some places their form was almost obliterated. 
The papillae, corium, and deeper tissues were replaced by the 
new formation, which consisted of adenoid tissue, made up 
of a network of pale, soft, anastomosing fibrillar, traversed by 
capillaries, running in all directions. ~No white corpuscles 
were found in the capillaries. The meshes of the network 
were filled with lymphatic cells. 

No specific treatment has been suggested. The prognosis 
is very unfavorable. 

* G-illot, loc. eit., p. 41. 



NEUROMA CUTIS. 505 

NEUROMA CUTIS. 

By the name of neuroma of the skin I would describe a 
disease characterized by the presence of variously sized and 
shaped neuromatous growths having their seat primarily in 
the true skin. The affection is an exceedingly rare one, and 
as there are, to my knowledge, but two cases upon record, one 
reported by myself,* the other by Kosinski,f I shall present 
an abstract of the cases themselves. 

Case I. — The patient is a man, aged seventy, who has 
been under my observation for the past six years.J The dis- 
ease began at the age of sixty, in the form of small, rounded 
tubercles, situated in the skin of the shoulder, attended with 
itching but not pain. For a period of four years they con- 
tinued to appear in numbers, so that by the end of this time 
the arm and shoulder were well studded with them. During 
the last six years they have manifested themselves at longer 
intervals, and their development has been slower, although 
new ones still make their appearance from time to time. 
The original tubercles have, within this term, scarcely in- 
creased in size. 

The disease is at present characterized by numerous small, 
split-pea sized, hard, rounded tubercles, occupying the left 
scapular region, shoulder, and outer surface of the arm as 
far down as the elbow. They are irregularly disseminated, 
and occupy no particular nerve tract. They are firmly in- 
corporated with the skin, and extend into the subcutaneous 
connective tissue ; they are immovable and not pedunculated. 
Over the shoulder and arm they are most numerous, and are 
closely packed together, the surface presenting a solid mass 
of hard, uneven, tuberculated tissue; about the scapular 
region, as well as farther down the arm near the elbow, they 
are more scattered and are discrete, the skin between them 
being in all respects normal. They are of a purplish-pink 



* Case of Painful Neuroma of the Skin. Amer. Jour, of the Med. Sci., 
Oct., 1873. 

f Neuroma Multiplex. Centralblatt fur Chirurgie, No. 16, 1874. 

X The notes describe the disease as it existed before the operation (in Octo- 
ber, 1874). The case is still under notice. 



506 NEW GROWTHS. 

or pinkish color, the shade varying with their age and loca- 
tion ; the more recent, isolated formations are either pink- 
ish or the color of normal skin. The color of the diseased 
surface, as a whole, varies greatly, according to the position 
of the limb, the temperature, and the presence or absence 
of pain. Fine, laminated, yellowish, glistening scales are 
slowly produced and shed from the tubercles, giving the 
affected part a dry, somewhat scaly aspect. The surface is 
warmer than the adjacent healthy skin ; during an attack of 
pain it becomes quite hot, and, at times, livid in color. Pain, 
paroxysmal in character, constitutes the distressing feature 
of the disease. This did not manifest itself till three years 
after the tubercles had begun to form, since which time it has 
increased gradually in severity to its present degree, which it 
attained some four years ago. 

The pain during a paroxysm is excruciatingly violent, 
shooting down the arm as far as the knuckles, across the 
chest, and up the side of the neck and head. The paroxysms 
usually last an hour or longer. Its exciting causes are move- 
ment of the affected part, exposure to cold air, and mental 
worry and excitement. Any decided change to bad weather 
is accompanied by a severe attack. There is greater immu- 
nity from pain in summer, or in a warm atmosphere, than 
in winter or during a rainy or snowy season. The nutrition 
of the arm is in no way impaired. The general health is 
good. 

Iso cause can be assigned for the disease. Microscopic 
examination of excised tubercles revealed the growth to be 
made up of a firm connective tissue containing numerous 
fasciculi of what in all probability were nerve fibres, running 
up as high as the papillary layer of the corium.* 

None of the various methods of treatment employed from 
time to time having proved of benefit, exsection of a portion 
(one inch) of the brachial plexus of nerves was performed by 

* In the first examination of the growth, the result of which was given 
with the report of the case, I was unable to demonstrate the presence of 
abnormal nerve structure. Since that time examinations of other more re- 
cently excised tubercles have shown the existence of the above described 
formation. 



NEUROMA CUTIS. 507 

Dr. F. F. Maury. The operation was followed by marked 
diminution of pain and considerable decrease in the size of 
the growths.* 

Case II. — Kosinski's case is briefly reported as follows: 
The patient was a man, aged thirty. The disease made its 
appearance in his sixteenth year. The tubercles were at first 
small and painless, but later grew in size and became pain- 
ful. The affection occupied the posterior and outer sides of 
the right thigh, as far down as the lower third, and a portion 
of the buttock. It was characterized by numerous (about 
one hundred), disseminated, more or less well-defined, round 
or oval tubercles, varying in size from a pinhead to a hazel- 
nut. They had their seat in the corium, extending into the 
deeper structures ; the smaller ones appeared to occupy the 
true skin alone. They were hard, elastic, and painful to the 
touch. The larger ones were semi-transparent in appear- 
ance. The surface of the affected skin was dry, uneven, and 
covered with a slowly desquamating, scaly epidermis. Pain 
was a marked feature in the disease. Upon pressure the 
growths, more especially the larger ones, were intensely 
painful, the pain radiating in all directions. Pain was pres- 
ent, moreover, in the affected part even during repose. 

Microscopic examination of excised tubercles showed them 
to be composed of " non-medullated nerve fibres and con- 
nective tissue." The growths were found to be supplied by 
the branches of the small sciatic and external cutaneous 
nerves. All other treatment having failed, a portion of the 
small sciatic nerve was exposed by an oblique incision in 
the gluteal fold, and an inch exsected. The operation was 
followed by an immediate diminution of pain in the tuber- 
cles and affected parts. Four months later they had nearly 
disappeared and were entirely painless. 

Attention has thus been called to two examples of a dis- 
ease which I believe to be entitled to the name under which 
they have been placed. It is without doubt closely allied, 
clinically as well as pathologically, to the affection known as 

* For a report of the operation and the details of its result, see the Amer. 
Jour, of the Med. Sci., July, 1874. 



508 NEW GROWTHS. 

" subcutaneous painful tubercle." It differs, however, from 
the subcutaneous painful tubercle, as originally described by 
Wood,* in having its seat primarily in the true skin and not 
in the subcutaneous connective tissue. The subcutaneous 
painful tubercle, as its name indicates, is situated beneath 
the skin, and is very often scarcely perceptible to the eye. 
It is always found to be freely movable under the skin and 
never in any way attached to it. It is, moreover, almost 
invariably a solitary growth. 

* Edinburgh Med. and Surg. Jour., 1812; and Trans, of the Med.-Chir. 
Soc. of Edinburgh, 1829. 



CLASS "VII I. 

NEUROSES. 

Under the head of neuroses are classed those disorders 
which are characterized by an alteration in the normal sensi- 
bility of the skin unattended by structural change. They are 
strictly functional in character, and depend upon an altered 
state of the nervous system, manifesting itself directly upon 
the cutaneous surface. The symptoms of neuroses conse- 
quently are purely subjective, no structural lesions or other 
objective symptoms primarily existing; secondary lesions, 
as scratch marks or artificial hyperemia, may be produced, 
but they must be viewed as consequent upon the original 
disturbance. 

The affections which are found in this class may be grouped 
into two divisions, termed hyperesthesia and anaesthesia. 

HYPERESTHESIA. 

Cutaneous hyperesthesia consists in an abnormal condition 
of the skin characterized by an augmentation in its general 
sensibility. It may be idiopathic or symptomatic; the latter 
variety is that usually encountered, the condition being 
secondary and manifestly dependent upon some more serious 
disease. Simple augmented natural sensibility, or simple 
hyperesthesia, may be either general or local, diffused or 
circumscribed. It may be unilateral or symmetrical. The 
temperature, as a rule, remains normal. The causes are 
varied, the condition being due either to some functional 
derangement of the nervous system, or to some organic dis- 
ease connected with the nerve centres or trunks. Hysteria 
and allied states are well known causes; also diseases of the 
brain, spinal cord and nerves. The sensation in the parts 
is unduly excited and exalted, the patient experiencing great 

509 



510 NEUROSES. 

discomfort from contact with the air, clothes, and other 
objects. The skin is exquisitely sensitive to all impressions. 
In duration it may be permanent or temporary, according 
to the cause which has occasioned it; ordinarily it exists as a 
passing derangement. 

DERMATALGIA. 

Syn. Dermalgia; Neuralgia of the Skin-, Rheumatism of the Skin; Ger?n., 
Nervenschmerz tier Haut ; Fr., Dermalgie. 

Dermatalgia is an affection characterized by pain having 
its seat solely in the skin, associated usually with a mor- 
bidly sensitive condition of the part, unattended by struc- 
tural change. 

Symptoms. — The symptoms of dermatalgia are entirely 
subjective.* There is absolutely nothing abnormal to be 
seen upon the skin. It presents no sign of eruption, nor 
is there any alteration in its thickness, coloration or tem- 
perature. To all appearance it is perfectly healthy. The 
disease may be general or local; commonly it is confined 
to a small area. All parts of the body may be invaded; 
it has, however, preference for the parts supplied with hair, 
as the scalp and extensor surfaces of the limbs. It is or- 
dinarily encountered in adult age, and is more frequently 
observed in women than in men. The affection is described 
by patients as consisting of an extremely sensitive state of 
the skin, accompanied by a feeling of positive pain, which 
is peculiar in that it has its seat in the most superficial 
layers of the integument. The attack is often quite 
sudden. The surface becomes remarkably sensible to all 
external impressions; the touch, and even the influence of 
the air, excite pain. In addition, the part is the seat of a 
spontaneous pain, which may be either continuous or in- 
termittent in character. It may be slight or very severe 
in degree, and is compared to sensations of burning, prick- 
ing, shooting, boring and the like. It is said at times to 
resemble a series of electric shocks; also, as though the 

* I am indebted for valuable information upon this affection to M. Beau, 
Archives Gen. de Medecine, Tome xii., Paris, 1841 ; likewise to M. Axenfeld, 
" Des Nevroses,"' Paris, 1864. Clinical experience has also furnished notes. 



DERMATALGIA. 511 

part were being perforated with pins or nails. It is also 
described as though the part had been denuded of epidermis 
and the papillae allowed to remain exposed to the air. The 
contact of external objects, as well as motion, always in- 
creases the pain; the rubbing of the clothes, or the mere 
touch of the finger, is sufficient to produce it. Gentle man- 
ipulation of the part causes a greater degree of pain than 
pressure. The passage of the fingers lightly over the surface 
will give rise to the sensation in a marked manner, whereas 
firm and forcible pressure will often relieve it. It is usually 
worse at night, and may be so severe as to prevent sleep. 
The course of the disease is indefinite; it may continue a 
week or a much longer period. Relapses may occur. 

Two kinds of dermatalgia are encountered, which may 
be designated respectively idiopathic and symptomatic. In 
the former the cutaneous symptoms exist apparently as the 
primary and sole disease, while in the latter, diseases of 
other organs primarily occur, as, for example, lesions of 
the nervous centres (locomotor ataxia), upon which the skin 
trouble is manifestly dependent. The idiopathic form is 
very rare; the symptomatic more common. The cutaneous 
symptoms are similar in both varieties. 

Etiology. — The causes which occasion the disorder are at 
times obscure. In considering this point it is of importance 
to discriminate between the idiopathic and symptomatic 
forms of the disease. The connection between rheuma- 
tism and idiopathic dermatalgia has been well established by 
the observations of Beau. This writer considers that the 
majority of these cases must be viewed as of a rheumatic 
nature. It is quite certain that in most of the recorded 
examples of the affection there has been a history of rheu- 
matism, either recent or remote. It, however, also occurs 
in those apparently in the best of health. It is not confined 
to those of nervous temperament. It has been observed to 
follow a general impression of cold. In other cases no cause 
whatever can be assigned.* The symptomatic form may be 

* A case of this kind, occurring in a gentleman, recently came under my 
observation. See also Piorry, " Memoire sur la Nature et le Traitement de 
plusieurs Nevroses," Paris, 1835. 



512 NEUROSES. 

caused by a number of conditions. Hysteria is one of the 
more common causes ; it is also known to accompany chlo- 
rosis.* Various diseases of the nervous centres, especially 
organic diseases of the brain and spinal cord, are now and 
then productive of it. 

Pathology. — From the character of the pain in idiopathic 
dermatalgia there can be no doubt that the disease has its 
seat in the upper layers of the skin, and, more definitely, in 
the papillary layer. It is remarkably superficial, and does 
not, as a rule, appear to extend even as far down as the 
subcutaneous tissues. As Axenfeld remarks, in addition to 
the location of the pain by the patient, its exasperation caused 
by the slightest touch proves conclusively that it is actually 
situated in the skin, and not simply referred there by the 
nervous centres. This writer adds, "that it is this which 
distinguishes it from the pains experienced in the skin by 
those affected with deeper neuralgias; these may coincide 
with actual anaesthesia of the integument over the region of 
the parts themselves where the pain is complained of. The 
dermatalgia which accompanies diverse neuralgias is only 
then, upon the whole, one of their possible symptoms, but 
not a necessary symptom." 

Diagnosis. — The affection may be confounded with simple 
hyperesthesia; this latter condition, however, usually ex- 
tends over a considerable surface, and is, moreover, un- 
accompanied by pain. Dermatalgia will be distinguished 
from pruritus by the usually limited area of surface at- 
tacked, and by the presence of the pain instead of itching. 
It should not be confused with pains in the nerve truuks, 
ordinary neuralgias, situated in the deeper structures, nor 
with muscular pains, which may involve the cutaneous tis- 
sues; the superficial character of the pain, appearing to be 
situated just upon the surface of the skin, will serve to 
distinguish it. 

Treatment. — This will depend upon whether it be idiopathic 
or symptomatic in form, and more particularly upon the cause. 



* See an interesting paper by Mordret, Prager Vierteljahrschrift, vol. 73, p. 
87 ; also Briquet, Traite clinique et therapeutique de l'Hysterie, Paris, 1859. 



PRURITUS. 513 

Rheumatism should always be suspected. In obstinate cases 
troubles of the nerve centres may be looked for. In the 
idiopathic form the disease usually disappears at the end 
of a few weeks, either with or without treatment. Local 
applications are at times demanded to relieve the acute 
symptoms of pain. A blister to the part, as recommended 
by Beau, will be found serviceable. Frictions are not to be 
employed. Vapor baths may be used in cases where the 
disorder is general. The galvanic current would doubtless 
prove a valuable remedy. 

Prognosis. — This will vary with the cause. In those symp- 
tomatic cases depending upon organic change in the nervous 
centres, it must be uncertain. It may or may not relapse. 



PRURITUS. 

Pruritus is a functional cutaneous affection, manifesting 
itself solely by the presence of the sensation of itching, 
without structural alteration of the skin. 

Symptoms. — The various forms of itching encountered in 
the course of many diseases of the skin accompanied by 
organic change, are in no way associated with the disorder 
under consideration. These have been mentioned and dis- 
cussed in connection with the diseases in which they occur. 
Pruritus, as just defined, stands forth a prominent and dis- 
tinct affection, entitled to separate and attentive study. As 
stated, the single symptom present is itching. There are no 
primary objective symptoms whatsoever; secondary lesions 
may or may not exist, their presence depending upon the- 
amount of irritation and scratching to which the skin has 
been subjected. 

The sensation of itching is variously described, as it is- 
dependent upon one cause or another, and as it occurs upon 
this or that region of the body. At one time it is spoken 
of by patients as an irritation in the skin, as though some 
irritating substance were in contact with the body, as, for 
instance, new flannel. In other cases it is that of formica- 
tion, as though minute insects were crawling over the sur- 
face, or were boring into the parts. Again it is a tingling. 



514 NEUROSES. 

sensation, accompanied by a desire to scratch. In this man- 
ner, according to the subjective condition of the individual, 
will it be likened to an endless variety of sensations. It 
may exist in all degrees of severity, from a slight annoyance 
to a terrible disease. 

One characteristic of the itching, in all cases, is that it 
produces an irresistible desire to scratch. This act, or its 
modification, rubbing, is invariably indulged in to a greater 
or less extent, and cannot be refrained from in spite of the 
strongest force of will. As a result the surface is generally 
seen to be roughened, hypersemic, an*d torn or excoriated to 
a slight or marked degree. The tracks of the nails are fre- 
quently visible in the form of streaks and superficial wounds. 
In other cases, notwithstanding the violent scratching, no 
excoriations or marks are to be observed, so that were it 
not for the statement of the patient we should be inclined 
to doubt the presence of disease. The itching may be in- 
termittent or continuous ; it is more apt to be the former. 
It is almost always worse at night. 

Pruritus may be general or local. . It is rare to observe it 
invading the whole surface at the same time, although the 
various regions of the body may in turn be attacked. Ordi- 
narily certain parts are chosen as its seat, where it remains 
permanently until it disappears spontaneously or is relieved. 
About the head it may attack the scalp or the face; when 
upon the face, the nose and mouth are particularly liable to 
be involved. The trunk is often the seat of the disease. 
The arms and legs are less frequently affected. The regions 
commonly attacked are the genitalia and anus. It is en- 
countered here more frequently in women than in men. 

Occurring about the female genital organs, it is important 
not to confound the disorder with other diseases of an itch- 
ing character which are apt to appear in this locality. The 
itching pay be seated in the labia, vagina, or clitoris, and 
constitutes a distressing and almost intolerable affection. It 
may occur at any period, but it is more frequently encoun- 
tered during middle life and old age. In children it is often 
associated with, and caused by, worms in the bowel. 

In the male, the scrotum is the part generally attacked. 



PRURITUS. 515 

It may involve this region alone, or it may extend along 
the perineum to the anus. The sensations are usually in- 
tensely annoying, and cause the patient to rub and scratch 
violently whenever the itching is present. It is worse at 
night, and is apt to come on immediately after retiring. It 
is greatly aggravated by warmth. These latter remarks 
apply equally to the disease in the female. 

The anus is a frequent seat of pruritus. It occurs here in 
both sexes, and in children as well as in adults. The itching* 
may be around the orifice or just within the rectum. It gives 
rise in some cases to considerable disturbance of the nervous 
system, rendering the sufferer very miserable. It is even 
more intolerable than any of the other local varieties. At 
times it is persistently present; more often it comes and 
goes through the day. It likewise is particularly annoying 
at night. 

Etiology. — The causes which are capable of giving rise to 
pruritus are extremely varied, and it is necessary to bear 
this in mind when investigating a case. It may be occa- 
sioned by physiological changes, as, for instance, those which 
take place in connection with the uterus during gestation, 
or, by irregularity of the menstrual function in young girls. 
It is occasionally associated with hysteria. These are well 
known causes. In like manner organic diseases of the uterus 
and ovaries are at times accompanied by it. 

Pruritus is, moreover, encountered in the course of certain 
other diseases ; kidney troubles and hepatic disorder are not 
infrequently productive of it. In obstinate cases sugar in 
the urine may be suspected. The urine in all cases should 
be carefully examined. Various diseases of the nervous 
system are likewise at times found to be the origin of it. 

Very often it is seen to be caused by gastro-intestinal 
derangement, constipation, and allied conditions. Genito- 
urinary diseases are well recognized causes of the affection ; 
also, hemorrhoids and ascarides. In these latter cases the 
disease is apt to locate itself immediately about the seat of 
the trouble. The ingestion of certain medicines is at times 
followed by pruritus; opium now and then acts in this 
manner. 



516 NEUROSES. 

It is of course to be distinctly understood that the affec- 
tion under discussion is in no way caused by parasites, either 
animal or vegetable. Pediculi may be present in pruritus, 
but if so the fact is to be regarded merely as incidental ; 
they are never the cause of the disease. 

Pathology. — Pruritus is a functional affection. It must be 
viewed as being due to reflex nervous action. The nerve 
disturbance, unaccompanied by structural change in the skin, 
constitutes the whole process. The tissues remain unaltered 
throughout the entire course of the disorder. The causes 
which give rise to it are often similar to those which occa- 
sion certain organic cutaneous diseases, as, for instance, 
urticaria; the effect upon the skin, however, is altogether 
different. In urticaria and other diseases intimately asso- 
ciated with nerve derangement, lesions of a definite form 
and character take place; in pruritus these are absent. It 
is a disease purely of sensation. 

Diagnosis. — If the definition be remembered, no difficulty 
can well arise in distinguishing pruritus. It is a disease of 
the skin absolutely without any primary sign of alteration in 
its structure. Nothing abnormal is to be seen except second- 
ary lesions, produced by mechanical means, as scratching and 
rubbing. The application of stimulating lotions, ointments 
and other substances, may also give rise to changes which are 
to be viewed as secondary. The diagnosis depends entirely 
upon the subjective symptoms as stated by the patient. 
Pruritus begins and runs its course as such; occasionally, 
owing to violent scratching, and the use of strong applica- 
tions, more or less dermatitis may be brought on. This 
complication, however, is not often encountered. 

It is of the first importance to distinguish between primary 
and secondary lesions, for if uncertainty exist upon this point, 
the difficulty at once becomes great. No primary structural 
lesions occur in pruritus. As the disease continues, scratch 
marks, torn follicles, with blood crusts of all sizes, roughened 
epidermis, hyperemia, congested follicles resembling papules, 
and other symptoms of a similar kind are observed; these 
are all to be viewed as secondary lesions. 

Prurigo, a name which until quite recently served for 



PRURITUS. 517 

several distinct diseases, is now acknowledged to represent 
a definite process.* (See p. 250.) It is a papular affection, 
with marked symptoms and a determinate course. Bearing 
its papular nature in mind, it should never be confounded 
with pruritus. The secondary lesions of pruritus, just re- 
ferred to, in my opinion, have heretofore been considered 
by most English writers as the primary papules of so-called 
" prurigo." Pruritus and prurigo must be clearly separated. 
The only symptom they have in common is one found ac- 
companying many cutaneous diseases, namely, itching. 

Pruritus may also be confounded with phtheiriasis, a con- 
dition caused by the presence of lice. The mistake cannot 
occur if the primary symptoms are borne in mind. The 
secondary symptoms of these diseases, however, are similar, 
and it is concerning these lesions that the error is apt to arise. 
In both complaints there are itching and scratch marks ; but 
the scratch marks are much more marked, as well as more 
definite in character, in phtheiriasis. The presence of the 
pediculi establishes conclusively the diagnosis of phtheiriasis; 
in pruritus they are absent. Of course, it is not impossible 
that pediculi may attack a patient suffering with pruritus, 
just as they may occur in connection with any other cutane- 
ous disease; such an event, however, is seldom noted. The 
scratch marks and excoriations of pruritus are rarely exten- 
sive; in phtheiriasis they are conspicuous and severe, and, 
moreover, are characteristic as regards their distribution 
and form. Thorough inspection of the body, and especially 
of the underclothes, is very necessary in making the exam- 
ination ; the parasites should be suspected in every case of 
so-called "pruritus." The diagnosis is thus arrived at by 
exclusion. 

Treatment. — This must vary according to the cause. Be- 
fore entering upon any plan of therapeutics the case should 
receive careful investigation and study, for a successful result 
will depend entirely upon the recognition of the cause. This 

* Much confusion lias long existed between pruritus, prurigo, and phthei- 
riasis ; but, as may be seen by reference to the description of these diseases, 
they are very different disorders as regards both their symptoms and their 
causes. If rightly comprehended they cannot be confounded. 



518 NEUROSES. 

once detected, the treatment becomes rational, and is usually 
satisfactory. Constitutional and local remedies are both 
demanded. 

The internal remedies to be employed are those which seem 
indicated for relieving the cause, of whatever nature this 
may prove. The bowels are to be regulated, and if habitual 
constipation exist, they are to be kept open quite freely by 
means of laxatives, saline preparations being preferable. If 
there is flatulence or dyspepsia of any kind, the diet should 
be prescribed with a view to avoiding all irritating and in- 
digestible articles of food. Exercise is also to be taken, as 
may seem proper. In certain cases close attention to details 
of this kind will be followed by gratifying results. Irregular 
menstruation is to be improved by attention to the general 
health, by the judicious use of iron, cod-liver oil, fresh air, 
aud outdoor recreation. When accompanying diseases of 
the kidney or liver, the treatment is to be directed against 
these organs, nor is improvement to be hoped for until the 
primary disease has been relieved. These remarks apply 
equally to affections of the nervous system and of the genito- 
urinary tract. In these cases the pruritus is purely symp- 
tomatic. Where the internal trouble is of an organic kind, 
it is not likely that the cutaneous complaint will be relieved 
until the cause has been at least modified. In certain cases 
carbolic acid in one, two or three minim doses, in pill form, 
three times daily, may be given with the hope of obtaining 
relief. The dose may be increased from time to time. 

External treatment is scarcely to be looked upon as cura- 
tive, but rather as affording temporary relief. Varied and 
uncertain success is apt to attend the employment of local 
remedies. Water in one form or another will be found to be 
invaluable. Both cold and hot douches, plain vapor baths, 
and baths containing medicinal substances, will often prove 
of the greatest service in allaying the intensely disagreeable 
sensations so bitterly complained of by the patient. The 
alkaline bath, composed of from three to six or eight ounces 
of the bicarbonate of sodium, or of from two to four ounces 
of the carbonate of potassium, or of from two to four ounces 
of borax, to thirty gallons of water, will at times afford 



PRURITUS. 519 

decided relief. Sulphuret of potassium, from one to four 
ounces to the bath, may be mentioned as being useful. 
Salt-water, and sulphur baths are also at times beneficial. 

Lotions, of one kind or another, are to be commended as 
especially serviceable in the treatment of the local varieties 
of the disease. The most valuable of all the antipruritic 
remedies is carbolic acid. It is to be employed in the 
strength of from five to ten minims to the ounce of water, to 
which, if considered desirable, may be added a half drachm 
of glycerine. The lotion may be made stronger, should the 
case require it; at times fifteen or twenty minims to the ounce 
are borne by the skin. The patient should be warned as 
to the blistering properties it possesses when used in strong 
solution. Alcohol is also an excellent remedy,' either alone 
or as a vehicle for other substances. Sponging the parts 
with pure alcohol is occasionally very acceptable. The cor- 
rosive chloride of mercury in the form of a lotion, a quarter 
or a half grain to the ounce of water or diluted alcohol, may 
very frequently be resorted to with benefit. Black wash, 
and lime water, may likewise be used. 

Morphia, one, two or more grains to the ounce of water; 
cyanide of potassium, from fifteen to thirty grains to the 
pint; sulphite of sodium, a drachm to the ounce; dilute 
hydrocyanic acid, from one to four drachms to the pint; 
chloroform; lead water; and dilute acetic acid; are all well- 
known and serviceable remedies which may be employed 
in obstinate cases. The strength of the various formulae 
mentioned may be altered to suit the case. 

Camphor, chloral, and borax are three useful substances ; 
they may be employed alone with water or alcohol, or in 
various combinations. A chloral lotion, varying in strength 
from ten to thirty grains to the ounce of water, may be 
employed at times with good result. Borax and morphia 
are often advantageously combined, as, for example, in the 
following : 

R Boracis, giv ; 

Morphise Sulphatis, gr. viii ; 

Glycerinse, fjss; 

Aquse, fjviiss. 
M. 



520 NEUROSES. 

Lotions of carbonate of potassium, four drachms to the 
pint of water; water of ammonia, one or more drachms to 
the pint of water; tobacco, in the form of infusion or de- 
coction, may be mentioned as being useful. Infusions and 
decoctions of white hellebore, belladonna, and aconite have 
also been recommended. 

Tar combined with an alkali, as in the " liquor picis alka- 
linus," is not infrequently found to be a valuable remedy; 
one, two or more drachms of this preparation (for formula 
see p. 191). to the pint of water may be used. Other tarry 
preparations may also be employed. In this connection the 
various tar and carbolic acid soaps may be mentioned as 
being of more or less service in mild forms of the affection ; 
they are, however, not to be relied upon. 

In pruritus of the female genital organs it is very often 
necessary to use the fluid preparations in the form of injec- 
tions into the vagina. For this local variety of the disease 
hot water applications and injections will frequently be found 
effective. Dr. Goodell, of this city, informs me that he re- 
gards the decoction of tobacco, employed as an injection, as 
one of the most valuable remedies in these cases. Dr. Gill, 
of St. Louis, speaks well of the nitrate of alumina, five or ten 
grains to the ounce of water, used as injection. 

In some instances ointments relieve more effectually than 
lotions, especially in the localized forms of the disease. They 
are prepared in various combinations, chiefly from the sub- 
stances which have been mentioned. Calomel, a half drachm 
or a drachm to the ounce ; cyanide of potassium, five or ten 
grains to the ounce; chloroform, from ten to thirty minims 
to the ounce ; are all useful in pruritus of the genitalia. A 
preparation, introduced to the profession by Dr. Bulkley, 
composed of camphor and chloral, according to the following 
formula, will be found of service : 

R Camphorse, 

Chloralis Hvdratis, aa ^i ; 

Ungt. Aquae Rosaa, %i. 
M. 

N.B. The camphor and chloral are to be rubbed together until fluid, and 
then added to the ointment. 



PRURITUS. 521 

Prognosis.— This should always be guarded. The disorder, 
as a rule, is exceedingly obstinate, and often extremely diffi- 
cult to relieve. The prognosis must depend entirely upon 
the nature of the cause, and the ability to remove it when 
discovered. The patient should be encouraged to persevere 
with the treatment. In grave cases, melancholic symptoms, 
and mental depression, are not infrequently present. The 
affection is a most distressing one, and calls for every effort 
on the part of the physician. 

Pruritus Hiemalis. — By this name I shall describe a pe- 
culiar form of pruritus, which, on account of its well-marked 
symptoms, is entitled to separate consideration.* The affec- 
tion consists in an irritable state of the skin, induced by 
and dependent upon atmospheric influences, accompanied 
by sensations of itching, smarting, tingling and burning, un- 
attended primarily by structural alteration. 

It is a disorder of cold weather, making its first appear- 
ance in the autumn, and continuing, as a rule, until spring. 
It is never present in the summer months. Its duration is 
variable ; in some cases it lasts but a few days or weeks, 
while in other instances it remains until the advent of warm 
weather. It is a common complaint in cold climates, and 
is found upon individuals of all ages, no particular period of 
life appearing to be more susceptible than another. It occurs 
in both sexes in about the same proportion. All parts of 
the body may be attacked, although it is found upon certain 
regions in an almost invariable manner. It is confined in a 
great measure to the lower extremities, its usual seat being 
upon the inner surfaces of the thighs, about the knees, in the 
popliteal spaces, upon the calves of the legs, and around the 
ankles. The non-hairy portions of the limbs are selected in 
preference to the hairy parts. Both lower extremities are 
attacked symmetrically. It is not a localized affection, — that 
is, does not remain fixedly upon any given portion of the 
body. The itching may be most marked here or there, 



* For a more complete description of this disorder, see author's original 
paper in Phila. Med. Tinies, Jan. 10, 1874. 



522 NEUROSES. 

as the case may be, or it may change from one locality to 
another. 

The trouble makes its appearance either gradually or quite 
suddenly in the autumn, and is characterized by a feeling 
of itching, smarting, or tingling, as though the person were 
clothed in new flannel. The amount of irritation varies ; it 
may be very slight, or so severe as to cause great annoyance. 
It possesses one peculiarity which is striking, — namely, the 
tendency to become aggravated towards night. It is always 
worse in the evening, as the patient is about to retire, and 
is at its height, as a rule, after the bed has been entered. 
At this time the desire to scratch and rub the affected parts 
is almost irresistible, and the individual usually gratifies the 
craving either until some relief is obtained or sleep termi- 
nates the distress. Upon awaking in the morning a little 
of the itching may again manifest itself, but generally it is 
insignificant, and no further thought is given the subject until 
the following evening, when the same symptoms reappear, 
and are exactly repeated. In this manner it continues day 
after day, with but slight intermission, until, at the end of 
an indefinite period, usually months, it gradually vanishes. 
The patient now remains free of it until the next autumn, 
when in all probability it will recur and run a similar course. 
It may relapse in this way year after year, or it may disap- 
pear at the end of the first attack not to return. There is 
no primary eruption of any kind connected with the dis- 
order, either at its commencement or at any time during 
its course. 

If the skin be minutely examined at the beginning of 
an attack, nothing . indicative of disease is to be detected. 
The skin looks quite healthy, with the exception that it is 
perhaps somewhat dry. The epidermis seems normal, and 
there is no desquamation. The parts are neither hot nor 
hyperamiic. The hair follicles are neither inflamed nor 
obstructed ; there is no accumulation of epidermis or other 
matter about their openings, nor are they at all promi- 
nent. Here and there an inflamed follicle may exist, but 
this condition occurs only accidentally (at this stage of the 
affection). The glands do not appear to be markedly de- 



PRURITUS. 523 

ficient in their secretion, nor is there any reason for sup- 
posing that they are deranged. In short, the subjective 
symptoms, which the patient communicates, alone convey 
an}' idea of the condition. 

If, however, the skin be seen after the complaint has 
existed for some time, it will be noticed to look otherwise 
than just described. Certain secondary symptoms now exist. 
The skin may be rough and harsh or slightly chapped, sore, 
and reddish. Many of the follicles are more or less in- 
flamed, giving rise to small, acutely congested papules. 
Some of the hairs are also torn and broken off short, close 
to their follicles. Here and there, or over a considerable 
surface, the skin looks irritated and inflamed, the result of 
scratching. The marks of the finger-nails are everywhere 
to be seen, in the form of streaks and variously sized ex- 
coriations and blood crusts. In fact, the appearances just 
detailed (and they are generally conspicuous) are produced 
solely by the hands of the patient; they are all secondary 
lesions, the effects of scratching. 

Concerning the etiology of the affection, it is known that 
it is intimately associated with atmospheric influences. It 
is emphatically a disorder of the cool weather, disappearing 
as soon as the warmer season establishes itself. It is most 
common in northern climates, decreasing in frequency and 
in degree as the south is approached. It occurs usually 
in persons in excellent health, the various functions of the 
economy being in perfect order ; the nervous system shows 
no sign of general impairment ; the bowels are not apt to 
be constipated, nor are any of the secretions deranged. It 
is found equally among those who live in luxury and com- 
fort, and those dwelling in poverty. It is not caused, or in 
any way influenced, by neglect of person or by inattention 
to cleanliness, for it exists in no greater proportion among 
the unwashed and dirty than among the cleanly; it is as 
frequent among bathers as among those who never use the 
bath. Nor is it caused by any peculiarity in the under- 
clothes worn ; neither flannel, woollen-wear, nor rough goods 
of any description, are the direct cause, although when they 
are used they always tend to aggravate the condition. Ex- 



524 NEUROSES. 

ternal irritation, therefore, has no share in the primary 
cause. 

It is liable to be confounded with other affections. It is 
a pruritus; and by this is meant a functional disturbance of 
the skin, unattended by eruption, and whose only symptom 
is itching. The secondary stage, after the complaint has 
existed for some time, shows objective symptoms, the result 
of scratching, rubbing, and at times the application of irri- 
tating substances of one kind or another. It is when in this 
stage that it is most likely to be mistaken for other affections. 
The line between the primary and secondary symptoms must 
be clearly drawn. The primary symptoms are subjective 
only; the secondary symptoms are objective, and are entirely 
artificial in their nature. 

Lichen pilaris is the affection most likely to be confounded 
with it; but when it is remembered that lichen pilaris is 
a disease of the hair follicles, consisting in an accumulation 
of epidermis and sebaceous matter about their openings, no 
difficulty can arise. There are other points of difference. 
In lichen pilaris itching may or may not be present; fre- 
quently it is absent. It is commonly seen upon those who 
do not bathe, the masses of epidermic product being per- 
mitted to remain about the hairs, where by degrees a slight 
conical elevation is formed, the hair or its stump perforating 
the centre of the mass. It is speedily relieved in the majority 
of instances by the free use of hot baths and soap. Pruritus 
hiemalis, on the other hand, is quite as frequent in bathers 
as in those who do not bathe, and presents no primary lesions 
of the follicles. Lichen pilaris has its favorite seat about 
the outer surface of the thighs; pruritus occurs anywhere 
upon the limbs, with marked predilection for the non-hairy 
parts. Lichen pilaris never occurs in the popliteal space; 
this is one of the common localities of pruritus hiemalis. 

With true prurigo (the prurigo of Hebra), distinct plastic 
papules exist; this pathological lesion alone will serve to 
distinguish it from pruritus. Itching, scratching, excoriations 
of the skin, and other like symptoms, due to the presence of 
pediculi, are here referred to merely for the purpose of stating 
that they have no share whatever in the pruritus under dis- 



ANESTHESIA. 525 

cussion. They may possibly exist coincidently at times, just 
as they are liable to be found upon any person, but they are 
in no way connected with the disorder. 

The most relief is to be obtained from the use of vaseline 
or cosmoline, glycerine, carbolic acid, and the tarry prepara- 
tions, in the form of lotions or ointments. Alkaline baths, 
from two to six ounces of bicarbonate of sodium to the bath, 
according to the susceptibility of the skin, will at times give 
satisfactory results; their use should be persevered in. The 
water should be sufficiently hot to allow the individual to 
remain in the bath for twenty minutes without feeling chilly. 
Upon getting out, the parts should be gently dried by patting 
with a soft dry towel. No rubbing or friction should be in- 
dulged in. The bath is to be taken in the evening, if pos- 
sible just before retiring; the patient should sleep as cool 
as possible. During the daytime the undergarments worn 
should be of an unirritating nature. The various other 
prescriptions, lotions, and ointments already referred to may 
also be used with more or less success. Internal treatment 
is of no avail. 

MYESTHESIA. 

Cutaneous anaesthesia is characterized either by diminished 
sensibility or by an absolute want of sensibility. It varies 
greatly in the degree of its development. It may be general 
or local ; circumscribed or diffused. In the majority of cases 
the condition is confined to certain regions. It may be uni- 
lateral or symmetrical. Anaesthesia manifests itself by the 
absence rather than by the presence of symptoms. The part 
so affected possesses a numb, dead feeling, or may be com- 
pletely without feeling. It may or may not be accompanied 
by diminution of temperature, arrest of nutrition, and other 
signs of nerve disturbance; symptoms of this character will 
be present or absent according to the cause. As a modifica- 
tion of anaesthesia there exists the condition known as "anal- 
gesia" or "anodynia," in which there is loss of sensibility to 
paiu. It may be partial or complete; when complete there 
is absolute immunity from pain, to such a degree that a pin 
may be thrust through the tissues without giving rise to 



526 NEUROSES. 

pain. Analgesia may exist alone, without anaesthesia, tactile 
sensibility being preserved ; or it may occur together with 
anaesthesia, in which case loss of sensibility both to touch 
and pain is present. It is encountered in syphilis* and in 
other diseases. 

Cutaneous anaesthesia may be idiopathic or symptomatic. 
Its causes are numerous and diverse in nature ; they may be 
divided into those having a central origin, and those which 
act from without. To the latter belong all those agents 
which are capable of producing local anaesthesia, as cold, 
freezing mixtures, carbolic acid, chloroform, ether, caustics, 
aconite, and other substances possessing like properties. 
Anaesthesia may also result from traumatism ; wounds and 
injuries to nerves, as is well known, are not infrequently 
followed by more or less complete loss of sensibility. 

Certain diseases in which the nerves become involved 
by the morbid process are also accompanied by anaesthesia; 
this is noted in a marked degree in leprosy; also in syphilis. 
Tumors of one kind or another pressing upon nerve trunks 
may also give rise to the condition. Diseases of the nervous 
system, both functional and organic, as, for example, hysteria 
and the various diseases of the brain and spinal cord, are not 
infrequent causes of anaesthesia. Finally, loss of sensibility 
may arise from the toxic effects upon the system of certain 
substances ; of these, chloroform, ether, opium, and lead may 
be mentioned. 

In certain cases of anaesthesia, to which the name of " anaes- 
thesia dolorosa" has been applied by Romberg, the patient 
suffers from intense pain, although there may be complete 
loss of all forms of sensibility. The pain may be burning, 
shooting, darting or boring in character. This affection is 
met with especially about the region of the trigeminal nerve, 
and is probably always symptomatic of organic disease of the 
nerve centres. 

* Syphilitic analgesia has been fully described by Fournier. Loc. cit., 
p. 783. 






CLASS IX. 
PAKASITES. 

This class stands upon an etiological basis. The diseases 
constitute a natural, intelligible, and satisfactory group. The 
so-called parasites of the skin belong to the vegetable and 
animal kingdoms, and are termed respectively vegetable 
and animal parasites. They derive their sustenance from 
the cutaneous tissues, and have their habitat either in the 
texture of the integument, as in the case of fungi and 
scabies, or upon its surface, strictly speaking, as in phtheiri- 
asis. The diseases due to the presence of a vegetable or- 
ganism, or fungus, are designated by the generic term 
"tineas"; they comprise tinea favosa, tinea circinata, tinea 
tonsurans, tinea sycosis, and tinea versicolor. The two im- 
portant animal parasitic affections are scabies and phtheiri- 
asis. (See p. 70.) 

The parasitic diseases of the skin occupy a prominent 
place in dermatology. They are met with everywhere; 
they occur, however, more frequently in certain countries 
than in others. They are more common in populous, over- 
crowded, cities than in the country. They are local affec- 
tions, and consequently are amenable to external treatment. 
They are all contagious, although by no means so to the 
same degree; some are highly contagious, while others are 
so only under certain circumstances. As a group they in- 
cline to pursue a chronic course, and may continue for an 
indefinite period. They are all curable, and are relieved 
by a class of remedies known as parasiticides. 

527 



528 PARASITES. 



TINEA FAVOSA. 

Syn. Favus; Porrigo Favosa; Crusted Ringworm; Honeycomb Ring- 
worm ; Germ., Erbgrind ; F>\, Teigne Faveuse. 

Tinea favosa is a contagious, vegetable parasitic disease, 
due to the achorion schoenleinii, characterized by one or 
more, discrete or confluent, split-pea sized, circular, cup- 
shaped, pale- yellow, friable crusts, usually perforated by 
hairs, accompanied by itching. 

Symptoms. — The disease may attack the hairs and follicles 
(tinea favosa pilaris), the epidermis (tinea favosa epidermi- 
clis), or the nails (tinea favosa unguium); occasionally all of 
these structures are invaded at the same time. Its common 
seat is the scalp. Other portions of the integument, how- 
ever, non-hairy as well as hairy regions, are also not infre- 
quently invaded; for example, the shoulders, arms, penis, 
scrotum, and thighs. 

It manifests itself at first by more or less, diffused or cir- 
cumscribed, redness and superficial inflammation with slight 
scaling, followed by the appearance of one or several small, 
pin-head sized, pale-yellow crusts, seated about the hair 
follicles. In the course of a fortnight they will have in- 
creased considerably in size, and are then to be recognized 
with the naked eye as fully formed "favus cups" or "favi," 
presenting the following characteristics. They consist of a 
peculiar, dry, crust formation. They are circumscribed, cir- 
cular in form, and are elevated from a half line to several 
lines above the level of the skin. In their early stage they 
are bound down to the skin by a layer of epidermis, which 
surrounds and overlaps their periphery; later, when the crust 
assumes size, this attachment breaks, leaving the edges of 
the favus free and above the level of the epidermis. They 
are distinctly cup-shaped, always possessing a marked de- 
pression or umbilication in their centres, through which one 
or more hairs usually protrude. In structure they are ob- 
served to be made up of a series of concentric layers or rings, 
compactly arranged one upon the other. In consistence they 
are quite firm, and in most cases retain their form for an in- 
definite period, or until destroyed by violence and contact; 



TINEA FAVOSA. 529 

when taken up between the lingers they are more or less 
friable, and very often crumble away under pressure like dry 
mortar. Owing to the concentric laminae the surfaces of the 
crusts are uneven ; not infrequently, from external causes, 
they are injured and broken, and then present a rough ex- 
terior. 

The color of the recent favu3 crust is pale-yellow or sul- 
phur-yellow. If the growth have existed for some time 
the brightness of the hue will have become tarnished by 
the deposit of extraneous matter, as dust, or applications 
which may have been used, and will then possess a dirty- 
yellowish color, similar to that observed in the crust of pus- 
tular eczema. 

The favi are seated quite superficially upon the integu- 
ment, and may be raised from their bed without difficulty. 
The skin beneath will be seen to be greatly depressed, smooth 
and shining or atrophied; often covered with a delicate layer 
of epidermis; hyperaemic or inflamed; or in a state of sup- 
puration. In old cases, where the skin is much irritated, 
pustules and suppuration not infrequently occur beneath 
and around the edges of the crusts. 

The amount of disease and the number of the favi present 
vary; it is usual to meet with several discrete lesions as 
well as with patches composed of two or more which have 
coalesced, forming irregularly-shaped masses, having a honey- 
comb appearance. The size of the favi varies according to 
their a^e; as ordinarily seen thev are about the size of split 
peas. 

Any part of the body may be the seat of favus; the scalp, 
however, as already stated, is its usual habitat. Occurring 
here, the disease is sometimes complicated with pediculi, 
while swelling of the glands of the neck, and small abscesses 
upon the scalp, are not uncommon. The general surface of 
the body may also be attacked, either together with the scalp 
or alone. The nails are frequently invaded. The growth 
finds its way even into the substance of the nail, causing it to 
become thickened, yellow in color, opaque, and brittle. It 
is generally observed to occur in connection with favus of 
the scalp, and is to be accounted for by the patient's scratch- 

34 



530 PARASITE?. 

ingthe head, and thus introducing the parasite beneath the 
nail. 

Tinea favosa possesses a peculiar odor, a symptom by 
which (when the disease is sufficiently developed) its pres- 
ence may very often alone be recognized ; it is that of mice 
or of stale straw. Usually it is plainly perceptible; in other 
cases it is faint. More or less decided itching accompanies 
the disease; it is generally one of the first symptoms noted, 
and may prove troublesome throughout the course of the 
affection. 

The hairs in favus of the scalp undergo, as a rule, con- 
siderable change ; they become lustreless, opaque, dry, brittle, 
and, at times, split longitudinally. In other cases they seem 
to be less extensively invaded. After the disease has existed 
for some time they loosen and come out or are scratched 
out, leaving bald patches with atrophy of the follicles and 
sebaceous glands. The baldness eventually is more or less 
complete, and is usualty permanent and disfiguring. 

The course of the disease is chronic; unless properly 
treated it may last for years or for a lifetime. Even with 
energetic remedies it is at times an obstinate affection, re- 
quiring the prolonged use of parasiticides and depilation. 
Relapses are liable to occur, especially in those cases which 
have not been subjected to thorough treatment. 

Etiology. — The cause of tinea favosa is found in the pres- 
ence and growth of a vegetable organism, known as the 
Achorion Schonleinii. It was discovered by Schonlein, of 
Berlin, in 1839, and was named after him by Remak. The 
disease is eminently contagious. It not infrequently attacks 
several members of a family. I recall an instance (in Lon- 
don) where thirteen members of one family, brothers and 
sisters, were, in the course of years, affected ; in another 
case, a mother and two children, constituting the whole 
family, were at the same time suffering from the disease. 
Similar instances are not rare. It does not, however, attack 
all persons with the same degree of readiness; some, owing 
to peculiarity of skin, state, of the general health, or other 
conditions, are more prone to its influence than others. It 
is much more common in children than in adults. It usually 



TINEA FAVOSA. 531 

attacks children in the first place, either de novo or through 
direct contagion, and is from them communicated to adults. 

Tinea favosa is emphatically a disease of the poor, being 
confined almost exclusive!}' to the lower classes. Favus 
patients will almost invariably be found to be improperly 
cared for, dirty, and ill fed. The disease is rarely, if ever, 
met with upon the cleanly and well nourished. It is very 
seldom encountered in private practice. It is rare in the 
United States. White,* of Boston, out of 5000 consecu- 
tive cases of skin disease met with in dispensary practice, 
reports but 17 cases, and more than half of thes^ were in- 
stances where two or three members of the same family were 
affected. In Philadelphia it is even more rare. In Scotland, 
on the other hand, the disease is not uncommon. Anderson, 
of Glasgow,-)- reports 156 cases out of 10,000 consecutive 
cases of skin disease encountered in dispensary practice. 
Favus is not an infrequent affection among certain animals, 
especially mice, rabbits, and cats, from whom it is often 
communicated to man. 

Pathology. — The disease may have its seat either in the 
hair follicle and hair or upon the surface of the skin ; the 
follicle and hair are the structures usually attacked. It is a 
local affection, and is due solely to the presence and growth 
of the parasite. The crust is made up almost entirely of 
fungus. Upon section it is seen with the naked eye to be 
composed of a porous mass, and to possess a pale-yellow 
or whitish color. Each crust is enveloped in a capsule, or 
" stroma," formed of a finely granular, amorphous substance. 
Under the microscope, the growth is observed to consist of 
both mycelium and spores in very great quantity, and in all 
stages of development. (See Fig. VI.) 

The mycelium is made up of narrow, apparently flattened 
tubes, or threads, which ramify in all directions without defi- 
nite arrangement. They average from ^V" (.002352 mm.) 
to -y" (.003024 mm.) in diameter.J They vary greatly in 



* Boston Medical and Surgical Journal, May 18, 1826. 

f Lancet, Nov. 11, 1871. 

% The measurements of the Achorion Sch5nleinii, Tricophyton, and Micro- 



532 



PARASITES. 



length. The}- are straight, curved, bent, or crooked, and 
incline to branch out in an irregular, forked manner. They 
have a watery, pale-grayish or pale-greenish color. The 
character of the mycelium differs considerably with the 
stage of growth. The filaments may be empty and simple in 
structure, or they may be in a state of fructification and con- 
tain spores, in which case they are known as "receptacles," 
" sporophores," or "spore-tubes." These differ from the 
simple mycelium in being here and there irregularly jointed, 




Fig. VI. — Achokiox Schonleixjt. (500 Diameters.) 
Showing simple mycelium, receptacles, broken mycelium, and free spores. 

and in many instances divided into numerous, delicately 
marked small partitions or spaces, containing granules and 
young spores; the contents vary with the stage of develop- 
ment. Very often they are seen to be divided and broken 
up in such a manner as to have the appearance of the links of 
a chain; in time these links become detached, either singly 
or in variously sized parts, and are found intermingled with 
the spores. The mycelium is usually abundant. 

sporon Furfur were made with -^th (Wales's) immersion lens, by Dr. Joseph 
G. Kichardson and myself. 



TINEA FAVOSA. 533 

The spores, or sporules, called also couidia, are irregularly 
shaped, small bodies, varying greatly in size. They average 
from T>y f (.002352 mm.) to -fa"' (.005291 mm), in diameter. 
They are round, rounded or oval; very often they are elon- 
gated, contracted in the middle, or flask-shaped. They have 
a grayish or pale-greenish, nacreous color, and refract light 
in a marked manner. They assume no disposition to group, 
nor to arrange themselves in any definite way, although they 
are frequently found in aggregations. They occur in great 
numbers, and are present everywhere, both in between the 
mycelium and in other portions of the field. In places they 
are so numerous as to form almost solid masses. Forms of 
the achorion intermediate between mycelium and spores are 
always present, and show the mode of development. Gran- 
ular matter also exists. 

The fungus of tinea favosa may be discovered under the 
microscope without difficulty at all stages of the disease. It 
is the most abundant and luxuriant of the vegetable parasites. 
When the affection attacks the hairy portions of the surface, 
the hairs are in all cases more or less extensively invaded, 
the bulb and root especially suffering from the ravages of 
the growth. The fungus penetrates into the follicles and 
into the root, and develops here in quantity; or it extends 
itself up the shaft, in which case the hair is more or less 
disintegrated; this latter course, however, rarely occurs to 
the same extent as in tinea tonsurans. 

The parasite when it attacks the nail may be readily de- 
tected in a section or in scrapings, presenting the same 
features as in the epidermis or hair, although the growth 
is seldom so luxuriant as in these latter structures, and 
consequently does not exhibit the same tendency to the 
formation of spores; mycelium, in its various stages of 
development, will usually be found to predominate. The 
achorion Scbonleinii is a distinct variety of fungus, and is 
capable of giving rise to one form of disease only, namely,, 
tinea favosa. 

Diagnosis. — In the majority of cases no trouble will be ex- 
perienced in the diagnosis. The small, circumscribed, well- 
detined, pale or sulphur yellow, friable crusts, circular in 



534 PARASITES. 

form, and hollowed out in the shape of a cup or saucer, 
seated upon a slightly inflammatory base, cannot be con- 
founded with those of any other disease. At times, how- 
ever, especially when they have existed for a long period, 
they are broken, their peculiar form more or less destroyed, 
and their surface coated with dirt and other extraneous 
matter, giving them an appearance not unlike the crusts of 
pustular eczema; favus and pustular eczema may, indeed, 
in these cases be readily confounded. The absence of the 
characteristic pustules of eczema, and of subsequent dis- 
charge and crusting, will serve to distinguish the diseases. 
Occasionally, however, the bases of favus crusts suppurate 
from excessive irritation of the scalp, and pustules may even 
appear here and there around the favi. The peculiar odor 
is almost always present where the disease exists in quantity, 
and usually affords a ready means of diagnosis. A history of 
contagion may very often be obtained. 

The microscope should always be employed in cases of 
doubt. No difficulty will be experienced in the examina- 
tion. A small fragment of. the crust should be placed upon 
a glass slide with a drop of dilute liquor potassse, and cov- 
ered with a thin glass. The specimen may be immediately 
viewed. A power of from 300 to 500 diameters is necessary 
to bring out the features described. 

Treatment. — In the treatment we are influenced by the 
seat of the affection, its extent, and the length of time it has 
existed. Occurring upon the scalp, its favorite locality, it 
constitutes a troublesome and often rebellious disease, and 
demands thorough handling. The two remedies are parasiti- 
cides and depilation. Whatever parasiticide is employed, 
it must be used energetically, and in such a manner as to 
insure the complete destruction of the fungus in the follicle 
as well as upon the surface. The hair is first to be cut as 
short as possible with scissors, after which the crusts are to 
be removed by means of poultices or applications of almond 
or olive oil, and soft soap and hot water, as in the case 
of pustular eczema of the scalp. Where the disease is 
extensive and of long standing, repeated applications may 
be necessary to accomplish the object. After the crusts 



TIXEA FAVOSA. 535 

have been removed, the scalp in severe cases will show 
marked depressions, areas of atrophy here and there, and 
baldness, either partial or complete, or patches of superficial 
ulceration with more or less abundant suppuration. This 
latter condition may bear a close resemblance to superficial 
syphilitic ulceration. 

Extraction of the hairs, or depilation, is now resorted to, 
and for this purpose a pair of forceps are employed. Depi- 
lation is a most valuable means of treatment for the cure of 
the disease; without it, indeed, cure, in the case of favus of 
the scalp, becomes a matter of great difficulty, if not impos- 
sible. Before depilation is practiced, the part to be operated 
upon should on each occasion be well anointed with a simple 
oil, preferably almond oil. For the extraction of the hairs, 
a forceps with broad blades should be used, that the hairs 
may be firmly and securely grasped to prevent their break- 
ing off at the level of the skin, an accident which, in the 
case of brittle hairs, is liable to occur. A few hairs only, two 
or three, should be seized at a time and carefully pulled out 
in the line of their long axes. The operation is not very 
painful. A small surface should be cleared each day. 

Immediately after the operation, one or another of the 
parasiticidal ointments or lotions is to be well rubbed into 
the part, and made to penetrate the hair follicles and come 
in contact with the fungus. Corrosive sublimate, in the 
strength of one or two grains to the ounce of water, is oue 
of the best parasiticides. Sulphite of sodium, oue drachm to 
the ounce of water, as a lotion; sulphurous acid, one part to 
two or more of water, as a lotion; sulphur, a half drachm or 
a drachm to the ounce of ointment; yellow sulphate of mer- 
cury, a half drachm to the ounce of ointment; are all valu- 
able remedies. The tarry preparations are also serviceable, 
either alone or in combination with other more active reme- 
dies; they may be employed where the itching is a promi- 
nent symptom. Care should be exercised not to make the 
preparations used too stimulating. 

The length of time requisite to effect a cure in favus of 
the scalp will depend upon its extent and other circum- 
stances; it may be stated, however, that in severe cases 



536 PARASITES. 

from two to four months are necessary. Depilation is to be 
repeated as often as may be demanded, until the new hairs 
assume a healthy state; they should be examined from time 
to time under the microscope. Favus of the epidermis is to 
be treated after the removal of the crust by one of the above- 
mentioned ointments, as in the case of tinea circinata, to be 
described. In favus of the nail, the parasiticide should be 
rubbed into and beneath the free border of the nail ; the 
nail, moreover, should be cut and scraped. 

In addition to the means just indicated for the relief of 
the disease, certain other measures remain to be mentioned. 
Cleanliness is essential ; it is, indeed, the first step in the 
treatment; without it but little progress can be made. In 
certain cases, good food, fresh air, and the use of tonics will 
prove of decided benefit. Hygienic measures are to be in- 
stituted and carried out as thoroughly as the case will allow. 
The contagiousness of the disease should be borne in mind. 

Prognosis. — This will depend upon the duration and extent 
of the disease, as well as upon the general condition ; dirty 
and neglected individuals recover much more slowly than 
those in better circumstances. The longer the disease is 
permitted to continue upon the scalp, the more likelihood is 
there of resulting baldness, atrophy, and cicatrix. Favus of 
the epidermis is seldom obstinate. 

TINEA TRICOPHYTINA. 

Under this name are included three varieties of disease, 
known as tinea circinata, tinea tonsurans, and tinea s}*cosis. 
They may be regarded as modifications of one disease, inas- 
much as they are produced by one cause, namely, the Trico- 
pliyton fungus. This growth when it attacks the general 
surface of the body gives rise to the condition termed tinea 
circinata; the scalp, hair follicles and hairs, tinea tonsurans; 
the hair follicles and hairs of the beard, tinea sycosis. Al- 
though these three affections are due to the same cause, they 
are nevertheless characterized by such distinctive features 
as to entitle them to separate description. Their treatment, 
moreover, is somewhat different. 



TINEA CIRCINATA. 537 



TINEA CIRCINATA. 

Syn. Herpes Circinatus ; Ringworm of the Body; Fr., Herpes Circine ; 
Tricophytie Circinee. 

Tinea circinata is a contagious, vegetable parasitic dis- 
ease, DUE TO THE TRICOPHYTON, CHARACTERIZED BY ONE OR MORE 
CIRCUMSCRIBED, CIRCULAR, VARIOUSLY SIZED, INFLAMMATORY, SQUAM- 
OUS PATCHES, OCCURRING UPON THE GENERAL SURFACE OF THE BODY, 
ACCOMPANIED BY ITCHING. 

Symptoms. — The disease begins as a small reddish spot, 
which in a short time extends itself peripherally and consti- 
tutes a circular patch.* As the process advances the skin 
becomes hypersemic or inflamed, and is attended either by 
a number of minute vesicles in the form of a ring or by 
desquamation; the latter course is the more common. 

When fully developed the patches are circular, and slightly 
elevated, especially about the margins, which are sharply 
defined against the healthy skin. They tend to assume a 
distinctly annular character (whence the name ringworm), 
owing to the disposition which the process manifests of dis- 
appearing in the centre while spreading on the periphery. 

The patches vary in size; they may be the size of a small 
coin or as large as the palm of the hand ; as usually encoun- 
tered they are about the size of a silver half dollar. One, 
two or more of them may exist, in which case they are apt to 
coalesce, forming semicircles and segments of circles. Ordi- 
narily, however, but two or three are present, and these dis- 
crete and upon different parts of the body. They are reddish 
in color, and are usually surmounted with thin, shreddy, 
grayish, adherent scales, which are more abundant about 
the margin; in the centre the surface is generally pale-red 
and only slightly scaly. The desquamation is, in the majority 
of cases, scanty. 

The vesicles, when the irritation to the skin happens to be 
sufficient to produce them, exist about the periphery in the 

* It will be understood that the following description applies to the dis- 
ease chiefly as it is encountered in this country. The severer forms of tinea 
circinata, as those encountered in certain parts of Europe and in tropical 
climates, are seldom if ever seen here. 



538 PARASITES. 

form of a ring; they are pin-point and pin-head in size. 
As a rule, they are ephemeral in character, and consequently 
usually escape detection. The disease is superficial, its seat 
being in the epidermis. The corium, however, is involved 
secondarily, and at times is the seat of a high degree of 
inflammation. The disease as a rule shows no disposition 
to symmetry, although it may so happen through contagion 
in certain regions, as the thighs, that both sides of the body 
are symmetrically affected. 

All parts of the general surface of the body may be at- 
tacked by tinea circinata; preference, however, is shown for 
certain regions, especially the face, neck, and backs of the 
hands. The inner surfaces of the thighs, between the nates, 
and about the genitalia, are also common seats for the dis- 
ease; attacking these localities, it is apt to spread extensively 
and at times to be remarkably difficult of treatment.* 

The course of tinea circinata is variable, depending upon 
the region attacked, age and general condition of patient, cli- 
mate, and other circumstances. It may run a brief course, 
lasting a few weeks, or, on the other hand, it may continue 
for months. Occasionally the disease exhibits a remarkable 
degree of obstinacy, showing itself repeatedly in the same 
region in the form of relapses, or manifesting itself from time 
to time in new localities. In the child it is usually very 
amenable to treatment, and not infrequently pursues a course 
terminating in spontaneous recover} 7 . In warm climates it 
is much more intractable than in temperate or in cold cli- 
mates. Tinea circinata may co-exist with tinea tonsurans; 
this occurrence, however, is seldom observed in this city. 

The tricophyton occasionally attacks the nails, causing 
the condition known as tinea tricophytina unguium. The 
nails become opaque, whitish, thickened, and soft or brittle, 
especially along their free border. It seldom happens that 
more than two or three nails are affected. 

* The disease which Hebra formerly designated "Eczema Marginatum," 
encountered in cavalry-men and others, occurring chiefly about the thighs, is 
to be viewed as a severe form of tinea circinata. It not infrequently takes 
on an eczematous aspect. The so-called Burmese and Chinese ringworms are 
of the same nature, and are due to the same parasite. 



TINEA GIROINATA. 539 

Etiology. — It is caused by the presence of the Tricophyton, 
a discovery made by Bazin, of Paris, in 1854.* It is the 
same growth which produces the diseases tinea tonsurans 
and tinea sycosis. It, however, shows itself in a quite differ- 
ent stage of development, seldom arriving at the luxuriant 
state attained in either of the just mentioned diseases. The 
affection is highly contagious, and is very frequently com- 
municated from one member of a family to another. It 
may also be contracted from cows, oxen and horses, the tri- 
cophyton being known to attack these animals. It is much 
more common in children than in adults, attacking infants 
as well as older children. It occurs more frequently in some 
countries than in others. Anderson, t of Glasgow, reports 
54 cases only out of 10,000 consecutive cases of skin disease 
encountered in dispensary practice; on the other hand, 
White,! of Boston, records 100 cases out of 5000 consecu- 
tive cases of skin disease met with at the out-door depart- 
ment of the Massachusetts General Hospital. It is now 
a well-established fact that all individuals are not equally 
susceptible to the ravages of the parasite. A certain condi- 
tion of the skin appears to be requisite for its development 
and growth. It will not take firm root upon every skin. 
The peculiar nature of the condition essential for its growth 
is unknown ; in some cases, however, especially in adults, 
the disease is noted to be dependent upon a depreciation in 
the general tone of the system, consequent it may be upon 
chronic constitutional disease or some temporary systemic 
derangement. It is met with among the poorly nourished 
and improperly cared for and also among those in the upper 
walks of life. 

Pathology. — The fungus alighting upon the surface finds 
its way into the epidermis, which it permeates in all direc- 
tions. At first hyperemia is produced, which is soon fol- 
lowed in the majority of cases by superficial inflammation, 
with or without slight vesiculation, and desquamation. The 
seat of the parasite is in the epidermis, and in this tissue 

* Considerations sur la Mentagre et les Teignes de la Face. Paris, 1854. 

f The Lancet. Nov. 11. 1871. 

X Boston Medical and Surgical Journal, May 18, 1876. 



540 



PARASITES. 



only, although the irritation occasioned affects the true skin 
to such an extent as to give rise very often to marked cuta- 
neous disturbance. As already stated, vesiculation may or 
may not be present; more or less desquamation, however, 
is always at hand, and is especially noticeable about the 
margin of the patch. As a rule, it is not very abundant, 
the scales beins: thin, shreddv and shrivelled. 




Fig. VII. — Tricophyton, as found in Tinea Circinata. (500 Diameters.) 
Showing mycelium and spores. 

Under the microscope the fungus is seen imbedded in the 
epidermic cells in the form chiefly of mycelium, the spores 
existing usually only scantily. (See Fig. VII.) The myce- 
lium consists of long, slender, delicate, sharply-contoured, 
pale-grayish, riband-like formations, or threads, containing 
here and there spores and granules. It is jointed at irreg- 
ular intervals, and is remarkable for its length, a single 
thread not infrequently extending itself over the field, send- 
ing off branches here and there in all directions. It varies 
from -1-2V" (.001764 mm.) to -gV (.002646 mm.) in diam- 
eter. It may pursue a straight, curved or crooked course; 

Where the fungus is abundant the 



verv often it is forked. 



TINEA CIRCIXATA. 541 

threads cross and recross one another in such a manner as to 
form an irregular network. 

The spores are small, round or roundish, highly refractive 
bodies, of a grayish or pale-greenish color. They do not 
assume the manifold forms met with in the achorion Schon- 
leinii or in the microsporon furfur. They vary from two'" 
(.002116 mm.) to ^"' (.003528 mm.) They are very per- 
sistent. They are met with singly or in the form of chains 
of two, three or more, and may be isolated or joined to the 
mycelium. 

The plant rarely grows very luxuriantly in tinea circi- 
nata, as encountered in this country; as a rule, it is apt to 
be scanty. It may, however, always be found in the early 
stage of the affection; later, it is not infrequently somewhat 
difficult of detection. 

Diagnosis. — This may be determined either by the clinical 
features of the disease or by means of the microscope. 
Where the fungus exists in profusion but little trouble is 
experienced in demonstrating it under the microscope; 
where, on the other hand, it is scanty, not a little micro- 
scopic skill is at times requisite to establish its existence. 
The examination is best made in the following manner. A 
few of the scales should be scraped with a blunt knife-blade 
from the suspected patch and placed upon a glass slide 
containing a drop of dilute liquor potassa?, over which is laid 
a thin glass cover. The cover should be carefully pressed 
down and the epidermic mass flattened out. Permitting the 
specimen to remain for a few minutes, in order that the 
caustic may separate the epidermic cells, it may be viewed 
with a power of from 300 to 500 diameters. The fungus 
will in most cases be detected here and there, having at first 
a faint outline, but becoming more distinct as the specimen 
stands. The parasite resists the caustic, and for a short 
time at least is not injuriously affected by it. 

It need scarcely be added that it is of the utmost impor- 
tance that the slide and cover be scrupulously clean and free 
of shreds of lint and other extraneous matter which is apt to 
adhere to the surface of the glass. The mycelium is liable 
to be confounded with fibrils of wool and cotton, which often 



542 PARASITES. 

become involved with the specimen, and with the margins 
of epidermic cells, which incline to overlap one another in 
a manner which often gives rise to an appearance resem- 
bling short mycelium. The outline of mycelium, however, 
is always distinctly defined, its walls showing parallel lines; 
the mycelial threads, moreover, usually stretch for a consider- 
able distance over the field, and contain spores and granular 
matter. The spores are to be distinguished from extrane- 
ous fatty particles, as the fat of ointments, which may have 
been used in the treatment; from sebaceous matter; from fat 
globules in fattily degenerated cells, as in seborrhcea ; from 
the nuclei of cells; from pus and other cells and granules. 
Where much fatty material prevails, the specimen may be 
advantageously submitted to a few drops of ether. 

Tinea circinata may be mistaken for a patch of squamous 
eczema, although its circular and often annular form, its 
abrupt margin, its slight and shreddy desquamation, together 
with its course and history, will usually render the diagnosis 
easy. The more aggravated varieties of the disease, as en- 
countered about the thighs and genitalia, resemble eczema 
more closely, and may indeed in some cases be complicated 
with eczema. The marginate character of the patches in 
these cases points in itself strongly to there being a parasitic 
element present. 

Tinea circinata bears a close resemblance to seborrhcea as 
it is met with on the body, especially the chest and back. 
Patches of seborrhcea occurring in these regions very often 
take on a circular and annular form, and are accompanied 
with desquamation very similar to that of tinea circinata. 
Ringworm, however, may always be known by its inflamma- 
tory nature, by its tendency to increase its area centrifugal ly, 
and by the absence of enlarged follicles and a greasy surface. 

It may also be mistaken for psoriasis, especially when the 
patch of psoriasis happens to assume the circinate form, as 
often occurs when the disease is about disappearing. The 
presence of psoriatic patches on other parts of the body, as 
well as the history of the case, will aid in the diagnosis. The 
microscope here, as in all doubtful cases, will decide the 
question. 



TINEA CIRCIXATA. 543 

Tinea circiiiata can scarcely be confounded with any of the 

manifestations of syphilis; the existence of other symptoms 
of syphilis, and the history, will assist in arriving at a conclu- 
sion. It may be known from tinea favosa of the epidermis 
by the absence of the characteristic, yellowish crust of this 
disease ; the patch of favus, moreover, is usually smaller and 
less distinctly circinate than that of ringworm. The micro- 
scope will in all cases determine the diagnosis, for the two 
varieties of fungi are quite different. 

Treatment. — As a rule, local treatment alone is required; in 
certain cases, however, particularly in adults, where the dis- 
ease continues persistently in spite of parasiticides, internal 
remedies of a tonic nature should be generously prescribed. 
The preparations of iron, arsenic in small doses, quinine, 
cod-liver oil, and the mineral acids, will all be found service- 
able remedies in these obstinate cases. They will very often 
prove of decided value in relieving the patient permanently 
of his trouble. In the majority of cases, however, as the 
affection exists in this country, the fungus has but a feeble 
hold on the skin, and is easily destroyed by any of the milder 
parasiticides. In the choice of a remedy the physician should 
be guided by the age of the patient, the extent and seat of 
the disease, whether localized or diffused, and the state of 
the skin as to the amount of inflammation, thickening, and 
irritability. 

In children weak applications are usually sufficient to re- 
move the disease. Washing the patch with soap and water 
and afterwards applying an ointment of ammoniated mer- 
cury, ten grains or a scruple to the ounce, will very often 
suffice. Ointment of the nitrate of mercury, a drachm to 
the ounce of simple ointment, or the yellow sulphate of mer- 
cury, ten or fifteen grains to the ounce of simple ointment, 
are also useful preparations. The corrosive chloride of 
mercury is also an excellent remedy, used either as a lotion 
with water or alcohol or as an ointment; in either form the 
strength should be from one to three grains to the ounce. 
Acetic acid, tincture of iodine, and cantharidal collodion, 
painted over the patches once or oftener; sulphurous acid, in 
the form of a lotion, one part to two or more of water ; hypo- 



544 PARASITES. 

sulphite of sodium, a drachm to the ounce, either as a lotion 
or as an ointment; are all serviceable remedies. When the 
patches are in a state of irritation, as occurs from the too 
frequent use of strong parasiticides, weak tar ointment, a 
half drachm or a drachm to the ounce, or carbolic acid oint- 
ment or lotion, five or ten minims to the ounce, may be em- 
ployed with benefit. Sulphur or mild mercurial vapor baths 
may in certain cases be resorted to with advantage. 

Whatever the remedy used, care should be taken that the 
skin be not irritated ; it should be remembered that the 
disease has a superficial seat, and is therefore easily reached. 
The ointments should be employed in small quantity and 
well rubbed into the affected part once or twice daily. If 
a mild lotion be used, it should be applied for ten or fifteen 
minutes on each occasion. 

Prognosis. — It is by no means always easy to predict the 
course of the disease; for, while the majority of cases yield 
readily to treatment, instances not infrequently present them- 
selves where the affection persists, off* and on, in the form of 
relapses, for a long period. This occurs more especially in 
adults. In children it may terminate spontaneously or with 
the aid of the simplest household remedies. Tinea circinata 
of the thighs and genitalia will be found the most trouble- 
some and obstinate local variety. 

TINEA TONSURANS. 

Syn. Herpes Tonsurans ; Trichonosis Furfuracea ; Ringworm of the Scalp ; 
Porrigo Furf'urans : Tinea Tondens : Germ., Scherende Flechte ; Fr., Her- 
pes Tonsurant ; Teigne Tondante ; Teigne Tonsurante. 

Tinea tonsurans is a contagious, vegetable parasitic affec- 
tion of the scalp, due to the tricopsyton, characterized by 
one or more circular, variously sized, scaly, more or less bald 
patches, showing the hair to be diseased and broken off close 
to the scalp, accompanied by itching. 

Symptoms. — It commences in the form of a small erythe- 
matous patch, rounded in shape, which soon becomes the seat 
either of a ring of minute, pin-head sized vesicles, ephemeral 
in character and which terminate in desquamation, or of 
furfuraceous scales. 



TINEA TONSURANS. 545 

The affection spreads rapidly, and in a short time attains 
its characteristic features, when it will be found to consist of 
one or more circular, circumscribed patches, varying in size 
from a small to a large coin, of a reddish, grayish or bluish- 
gray color, covered with tine, powdery scales, with the hairs 
broken off close to the scalp. The color of the patch varies 
with the complexion of the subject; in dark-haired children 
it is of a bluish-gray, leaden or slate color. The scalp is 
more or less raised and puffed out, and the follicles as a rule 
prominent, giving the surface a goose-skin or "plucked fowl*' 
appearance, characteristic of the disease ; it is most marked 
after the hairs have fallen out. The hairs are uniformly 
short, rarely more than a line or a line and a half in height, 
are thickened, twisted and bent, and look as though they 
had been broken off; their free extremities present a ragged, 
uneven, stubble-like look, as though the hair had been cut 
with a blunt pair of scissors ; they have a " nibbled" appear- 
ance. They lack their normal lustre; are dull and lifeless, 
opaque in color, and upon extraction are found to be dry, 
harsh, and brittle. They are seated loosely in their follicles, 
from which they may be removed without pain ; they are 
liable to break off close to the scalp in the attempt to extract 
them. As the disease progresses they incline to rupture, 
owing to the excessive infiltration of the fungus, and drop 
out of their own accord. As a result of the loss of hair, 
baldness, more or less complete, exists; it is, however, usu- 
ally only temporary, the growth of hair returning sooner 
or later. When the disease is fully developed the scales are 
comminuted and are present in the form of a line, mealy, 
grayish powder. 

The patches are seldom larger than a silver dollar, al- 
though two or more upon the same region not infrequently 
run together, thus forming quite extensive areas of disease. 
Having started, they grow rapidly until they attain their 
determinate size, manifesting a marked disposition to re- 
cover in the centre while spreading upon the circumference. 
One, two or more may exist. They may have their seat upon 
any part of the scalp, although they show preference for the 
sides, over the region of the parietal bones. More or less 

35 



546 PARASITES. 

itching is always experienced; it is usually one of the first 
symptoms noted, and may prove annoying throughout the 
course of the affection. 

Tinea tonsurans may spread on to the side of the face, in 
which case it becomes tinea circinata. It is at times asso- 
ciated with tinea circinata; the two forms of disease may 
occur simultaneously or either may precede the other. Per- 
mitted to run on without treatment, it may continue indefi- 
nitely, as in the case of the other vegetable parasitic diseases ; 
on the other hand, it at times terminates in spontaneous 
recovery. 

Etiology. — The cause of the affection is found in the pres- 
ence and growth of the Tricophyton, the same fungus which 
gives rise to tinea circinata. The disease is a common one, 
and is met with universally. It is an affection of childhood, 
being very rarely if ever encountered in adult age, and sel- 
dom after puberty; on the other hand, it is rare in infancy. 
It is highly contagious, and may readily be communicated 
from one child to another by means of wearing apparel, caps, 
combs and brushes, towels, and bed linen. Its contagious 
properties are frequently manifested in schools and chil- 
dren's asylums, where a number of inmates become affected 
at the same time. It is liable to attack all classes, the rich 
as well as the poor, but especially those who are in ill 
health and debilitated. It is prone to occur among those 
who are improperly cared for and dirty. Cases are often 
met with in which it has been contracted from a patch of 
tinea circinata existing upon the mother or attendant. 

Pathology. — Under this head are to be considered the 
changes which take place in the hair, hair follicle, and epi- 
dermis, as well as the peculiarities of the fungus. The para- 
site was discovered by Gruby, of Paris, in 1844, and fully 
described by Malmsten, a Swede, in 1846, and named by him 
"tricophyton tonsurans." It invades the hair, hair follicle, 
and epidermis. The hair, however, suffers most severely, 
becoming in a short time filled with the growth, to such an 
extent usually as to cause its complete disintegration and 
destruction. The follicle also is attacked, and becomes dis- 
tended and prominently raised. 



TINEA TONSURANS. 



547 



The fungus is the same as that of tinea circinata, and has 
been considered in connection with that disease. It, how- 
ever, exists here in a different stage of development from 
that observed in tinea circinata. In tinea circinata the epi- 
dermis is the seat of disease; in tinea tonsurans the hair is 
the structure chiefly attacked. The fungus is found in tinea 




Fig. VIII.— Trichophyton, as found in Tinea Tonsurans. (300 Diameters.) 
Short, broken-off hair of scalp, invaded with free spores and chains of spores. 

tonsurans to be in a state of exuberant growth, the spores 
being thrown out from the mycelium in great profusion. 

As seen under the microscope, the broken hairs are in- 
vaded throughout their length with spores and jointed 
mycelium, the former in all cases markedly predominating; 
very often little or no mycelium is to be found. The spores 
are very numerous, and exist around the outside of the bulb 



548 PARASITES. 

and root, as well as inside the hair, where they take more or 
less complete possession of the structure. They are found 
in rows running parallel to the filaments of the hair or in 
irregularly disposed masses. The bulb and root are usu- 
ally so extensively invaded as to be literally crammed with 
spores, appearing as a solid mass resembling fish-roe, at 
times completely obliterating the hair structure. The hair 
is seen to be distended, or ruptured here and there along 
its shaft, the filaments protruding at these points, giving its 
exterior a rough, uneven surface. It is at times split up 
longitudinally, its component parts separated and barely 
holding together. In some cases the fungus is so abundant 
as entirely to disintegrate the hair. The free end of the 
shaft, at the point of fracture just beyond the level of the 
scalp, always possesses a jagged, bristly, stubble-like ex- 
tremity, consisting of broken filaments, between which 
spores may be found. (See Fig. VIII.) 

The furfuraceous scales scraped from the surface of the 
patch also contain fungus, although not to the same extent 
as the hairs, for the disease attacks the hair to the compar- 
ative exclusion of the epidermis. The amount of irritation 
to the skin varies; usually it is slight, giving rise merely to 
more or less desquamation or to the formation of ephemeral 
vesicles; in other cases it is severe, causing oedema and in- 
flammatory symptoms with fluid exudation, as occurs in the 
variety of the disease termed tinea kerion, to be described. 

Diagnosis. — In the majority of cases the diagnosis is suffi- 
ciently easy. There are, however, several diseases with which 
it may be confounded. Squamous eczema is frequently met 
with about the scalp assuming the form of one or more 
patches which may resemble those of tinea tonsurans. The 
histories of these affections are very different, and will alone 
usually suffice to distinguish them. In eczema there is no 
history of contagion, a point which can generally be estab- 
lished in tinea tonsurans. Squamous eczema of the scalp 
is usually a chronic disease; tinea tonsurans, on the other 
hand, generally pursues a rapid course, spreading da}' by 
day until a considerable surface becomes involved. The 
patches of eczema are not apt to be sharply defined, nor are 



TINEA TONSURANS. 549 

they usually circular as in tinea tonsurans. The hairs in 
eczema remain firmly implanted in the scalp; in tinea ton- 
surans they are always loose, and can be readily plucked 
out in numbers without causing pain. In eczema, moreover, 
the characteristic, thickened, brittle, brokeu-off and twisted 
hairs, as well as the peculiar color of the patch, covered with 
fine, furfuraceous, grayish scales, are absent. In doubtful 
cases, the microscope will always reveal the presence of the 
parasite in tinea tonsurans. Itching is, as a rule, a much 
more prominent symptom in eczema than in tinea tonsurans. 
In certain cases eczema may supervene upon or be compli- 
cated with the disease under consideration ; this occurrence, 
however, is rare. 

Tinea tonsurans may be mistaken for seborrhcea of the 
scalp. There is, however, in this latter affection no history 
of contagion ; the patches, moreover, are seldom circular, 
nor are the hairs implicated as in tinea tonsurans. The 
course of these two diseases is very different; seborrhcea is 
always a more or less chronic disorder. 

Psoriasis may at times present an appearance not unlike 
tinea tonsurans ; but the absence of the history of contagion, 
the healthy state of the hairs, the quantity and character of 
the scales, as well as its course, will always serve to distin- 
guish it from tinea tonsurans. 

Tinea favosa in its earliest stage, before the formation of 
the crust, may be mistaken for tinea tonsurans; in a short 
time, however, the characteristic, yellowish crust shows itself, 
and no further difficulty will be experienced. 

Certain cases of alopecia areata may be confounded with 
tinea tonsurans; this is a mistake of not infrequent occur- 
rence. In typical examples of alopecia areata, the absence 
of all hair from the patch, and the whitish, smooth, pol- 
ished-surface, will be sufficient to establish the diagnosis; 
the history, moreover, will be of assistance. In other cases, 
where the characteristic symptoms are in a measure want- 
ing, recourse must be had to the microscope, which will at 
once determine the diagnosis: in tinea tonsurans the tri- 
cophyton generally exists in profusion ; in alopecia areata 
there is no fungus. 



550 PARASITES. 

The microscopic examination of the hair offers no diffi- 
culty. The parasite is readily detected. One or two of the 
short, stumpy, broken-off hairs should be placed upon a slide 
with a drop of dilute liquor potassas and permitted to stand 
a few minutes, when, under a power of 300 diameters, the 
fungus as well as the lesions of the hair will be plainly visible. 
(See tinea circinata, diagnosis of.) 

According to Dr. Duckworth, of London,* the action of 
chloroform upon patches of tinea tonsurans is specific, and 
serves as a ready test for this disease. If a few drops be 
poured upon a patch and allowed to evaporate, a peculiar 
appearance is observed in the affected hairs and upon the 
skin at the openings of their follicles; they become whitish 
or light-yellow in color and remain so, the part looking as if 
sprinkled with a film of sulphur powder. Chloroform has no 
such effect upon healthy hair. The same change has been 
noted in connection with tinea circinata, tinea versicolor, 
and tinea favosa of the epidermis,! the patches assuming a 
whitish, powder} 7 appearance. 

Treatment. — It will be borne in mind that the same fungus 
exists here as in tinea circinata, although in a much more 
luxuriant state of growth ; the disease, consequently, is 
amenable to the remedies referred to in speaking of tinea 
circinata. The destruction of the parasite, which has its 
seat in the hair structure as well as in the follicle, is best 
accomplished by extraction of the hairs, together with the 
use of suitable parasiticides. As a rule, external remedies 
are all-sufficient to bring about a cure ; in some cases, how- 
ever, when the affection is of a severe type, and is rebellious 
to local treatment, constitutional remedies, as iron, arsenic, 
and cod-liver oil, may be resorted to with advantage. Strict 
attention to cleanliness is in all cases most important, not 
only with the view of hastening the cure, but of preventing 
contagion. The patient should be provided with special 
wearing apparel, combs, brushes, towels, bed linen, etc. 

The patches should first be cleansed as thoroughly as pos- 



* British Medical Journal, Xov. 1, 1873. 
,|St. Bartholomew's Hospital Keports, vol. ix. 



TINEA TONSURANS. 551 

sible with soft soap and water, and dried. The loose hairs 
about the edges of the patches, and the stumpy, broken-off 
hairs over the surface, may now be extracted. The short 
hairs are best depilated by meaus of a small, broad-bladed, 
short forceps, one, two, or three hairs being seized at a time. 
(See the treatment of tinea favosa.) A portion of the dis- 
eased hairs may thus be removed each day until the surface 
has been well cleared. After each depilation a parasiticide 
is to be applied, in the form of an ointment, oil, or lotion, as 
may seem indicated. Corrosive sublimate, as an ointment 
or lotion, one or two grains to the ounce of simple ointment, 
water or alcohol, answers very well. It has the advantages 
of being cleanly, of having no unpleasant odor, of not dis- 
coloring the skin, and of being at the same time effective. 

Tincture of iodine, of full strength or diluted, will also 
prove serviceable. A preparation much used in London, by 
Mr. Coster and others, is the following: 

R Iodini, ^ii ; 

01. Picis, f ^i. 
Misce et solve. 
N.B. The iodine and oil of tar should be gradually 
and slowly mixed. 

A small quantity of the above is painted upon the patches 
with a brush and allowed to remain on until the crust is cast 
off, in the course of five or six days, when it may be re- 
applied. A few applications usually suffice. 

Equal parts of tar ointment and sulphur ointment, or sul- 
phur ointment alone, a drachm to the ounce, are useful 
preparations. The late Mr. Startin, of London, esteemed 
the following : 

R Sulphuris Sublimati, ^ss ; ; 

Hydrargyri Ammoniati, gr. x ; 

Hydrargyri Sulphureti Nigri, gr. x; 
Misce et adde 

Olei Oliva?, f£ii ; 

Creasoti, gtt. iv^ 

Adipis, ^vi. 
M. Ft. ungt. 

Painting the patches with glacial acetic acid or cantharidal 



552 PARASITES. 

collodion once a week or oftener, and making use of one of 
the milder parasiticides in the mean time, is also a good 
method of treatment. Nitrate of silver in solution, a half 
drachm or a drachm to the ounce of water, is a well-known 
remedy which may be referred to. 

Among the milder remedies sulphurous acid, one part 
to three or six of water; sulphuret of potassium, fifteen or 
thirty grains to the ounce of water ; hyposulphite of sodium, 
a half drachm to the ounce of water; may be mentioned 
as the most useful. Sulphite of sodium, a half drachm or a 
drachm to the ounce, is also employed advantageously as an 
ointment. The milder parasiticides, just mentioned, should 
be used freely; in the case of lotions, they should be applied 
often, and for ten or fifteen minutes at a time; ointments 
should be slowly and thoroughly rubbed into the patches, 
and also around their edges. 

Any of the other preparations mentioned in connection 
with the treatment of tinea favosa or of tinea circinata may 
also be resorted to. 

Prognosis. — In the majority of cases no difficulty is expe- 
rienced in relieving the disease. The prognosis, however, 
must depend upon the length of time the affection has con- 
tinued, the extent of surface involved, the number of patches, 
and the amount of cutaneous irritation present. The state 
of the general health and the hygienic condition of the pa- 
tient must also be taken into account ; in children who are 
dirt}-, neglected and ill fed, it is generally more rebellious 
than iu the well-cared-for. In asylums and schools it is 
more difficult to control than in isolated cases. Sponta- 
neous cure may take place, although, as a rule, the disease 
when left to itself runs on indefinitely. 

Tinea Kerion. — Under this name is to be described a 
peculiar form of tinea tonsurans occasionally met with. It 
was originally described by Celsus ; more recently by Wil- 
son, Tilbury Fox, and others. It may be viewed as an 
aggravated tinea tonsurans, accompanied by oedema, inflam- 
mation, and the exudation of a viscid, glutinous, yellowish 
secretion from the openings of the hair follicles. The con- 
dition is analogous to that seen in tinea sycosis. It may 



TINEA SYCOSIS. 553 

occur with the usual form of tinea tonsurans or alone. It 
begins generally as ordinary tinea tonsurans, and is followed 
in a short time by tumefaction and deep-seated inflammation. 
When fully developed the patches are reddish or purplish 
In color; are more or less raised, cedematous, and bo^v : 
are uneven, honeycomb-like (whence the name kerion), and 
studded with yellowish, suppurative points, or, later, with 
small cavities, or foramina, the openings of the distended 
hair follicles deprived of their hairs ; and discharge a mucoid, 
gummy, honey-like fluid, which is observed to ooze from the 
patulous follicles. The secretion may be copious or scanty, 
according to the amount of inflammation and cutaneous 
disturbance. The patches are generally tender and painful, 
and at times the seat of considerable itching and burning. 
The course of the affection is chronic; it may continue 
indefinitely unless checked by appropriate treatment. In 
severe and protracted cases the hair follicles are destroyed, 
and there results permanent baldness. 

The causes which occasion this form of the disease rather 
than that usually encountered, namely, ordinary tinea ton- 
surans, are not known. It is met with in the upper classes 
as well as among the poor, although without doubt more 
common among the latter. It is rare in Philadelphia ; less 
so, I believe, in New York. It is to be diagnosed from sub- 
cutaneous abscess, which it at times closely resembles. The 
treatment is that of tinea tonsurans. 



TINEA SYCOSIS. 

Si/n. Sycosis Parasitica; Sycosis Parasitaria; Sycosis Contagiosa; Para- 
sitic Sycosis; Parasitic Mentagra; Barber's Itch ; Germ., Parasitare Bart- 
finne; Fr., Tricophytie Sycosique ; Sycosis Parasitaire. 

Tinea sycosis is a contagious, vegetable parasitic affection, 
due to the tric0phyt0n, confined to the hairy portion of the 
face and neck in the adult male, characterized by disease 

OF THE HAIR AND HAIR FOLLICLE, INFLAMMATION OF THE SKIN AND 
SUBCUTANEOUS CONNECTIVE TISSUE, AND THE FORMATION OF TUBER- 
CLES AND PUSTULES. 

Symptoms. — The disease commonly commences with one 
or more rounded, circular or semicircular, reddish, slightly 



554 PARASITES. 

scaly patches, the size of a small coin; in fact, as a tinea cir- 
cinata. In the course of a few clays or a week the redness 
and desquamation become more marked, and decided swell- 
ing and induration are noticed. The hairs also are noted to 
be affected; they are dry, brittle, incline to break, and are 
perhaps already loose. This condition of the parts now in- 
creases rapidly, from day to day, until in a short time the 
skin becomes distinctly nodular and lumpy, with points of 
pustulation about the openings of the hair follicles. Xot 
only the skin but also the deeper tissues are involved, giving 
rise to thick, bunchy, firm or even quite hard masses of 
induration. The surface is of a deep-reddish color; has a 
passively congested appearance; and is studded with vari- 
ously sized tubercles and pustules, which render the part 
greatly disfigured. The tubercular formations are a charac- 
teristic feature of the disease. They vary as to shape and 
size, but are for the most part irregularly rounded, and as 
large as split peas and hazelnuts. Very commonly they 
coalesce, producing large, uneven, lumpy patches. The 
amount of suppuration varies, depending upon the irritation 
of the fungus and the grade of inflammation set up. In cer- 
tain cases it is an early symptom, and proceeds actively, pus- 
tules of all sizes forming about the follicles; at times these 
break down, and are succeeded by thick crusts similar to 
those of pustular eczema. Beneath these crusts will usually 
be found an uneven, moist or raw, red surface, with yellowish 
points, discharging a glairy, glutinous material, and resem- 
bling in appearance the cut surface of a fig (whence the 
name sycosis). In other cases but slight pustulation takes 
place, the process being one rather of deep-seated tubercular 
induration throughout its course. 

The hairs are plainly diseased; they are dry and brittle, 
bent or broken off short either at their exit from the follicles 
or at a line or two above the level of the skin, and can be 
extracted without pain. Later, the hairs loosen spontane- 
ously, through suppuration or disintegration from excessive 
invasion of the fungus, and drop out, leaving the part devoid 
of hair. In other cases the hair follicles and hairs are in- 
volved to a less extent, so that loose hairs are found only 



TINEA SYCOSIS. 555 

here and there; the disease being one, as it were, midway 
between tinea circinata and tinea sycosis. 

The chin, neck, and the submaxillary region are the locali- 
ties commonly attacked; the cheeks and upper lip are rarely 
invaded. The disease may occur on one side of the face only 
or, as is usually the case, on both sides; as a rule, the whole 
of the region of the lower jaw is involved. 

The amount of itching, burning, and pain varies; at times 
these symptoms are slight, in other cases quite severe; they 
are, however, in almost all instances disproportionate to the 
severity of the lesions and cutaneous disturbance, and are 
seldom so marked as in non-parasitic sycosis. 

The course of the disease is usually chronic. As a rule, 
a few weeks suffice for it to present its characteristic appear- 
ance, after which it may continue spreading, or it may sub- 
side into an inactive state, according to circumstances. In 
the majority of cases it proves obstinate; even under judi- 
cious treatment it often shows itself rebellious. When left 
to itself it may last months or years, relapsing from time to 
time. 

It may develop from a previous tinea circinata of the non- 
hairy part of the face or of some other region of the body; 
or it may occur simultaneously with a tinea circinata of the 
general surface. 

Etiology. — The cause is found in the presence and growth 
of the Tricophyton fungus, which invades the hair follicle 
and hair. It is the same parasite as that of tinea tonsurans 
and tinea circinata. Its parasitic nature was pointed out by 
Gruby, of Paris, in 1842. It is eminently contagious, and 
is acquired in most cases from the razor or from the hands 
or toilet articles of the barber, All individuals, however, 
are not equally susceptible to the influence of the parasite; 
out of a number who have been exposed to contagion, cer- 
tain persons only will contract the disease. Like the other 
vegetable growths it seems to require some peculiar, un- 
known condition of the skin for its development. 

Tinea sycosis is not a common disease. The frequency of 
its occurrence varies greatly in different countries; it varies, 
moreover, in different sections of our own country. In Bos- 



556 PARASITES. 

ton it is about as common as tinea tonsurans; out of 5000 
consecutive cases of skin disease met with in dispensary 
practice, White* reports 38 cases of tinea sycosis and 42 cases 
of tinea tonsurans. Wigglesworth,f out of 1339 consecutive 
cases of skin disease, reports 8 cases of tinea sycosis. In 
New York the disease is of decidedly less frequent occur- 
rence; BulkleyJ encountered but 2 cases among 1617 cases 
of cutaneous disease, as met with in dispensary practice. In 
Philadelphia, in dispensary service, the proportion is even 
less; out of 1267 consecutive cases of skin disease observed 
at the Dispensary for Skin Diseases, no cases of tinea sycosis 
were recorded. The disease in this city, however, is by no 
means so rare as these figures indicate, for my private practice 
has recently afforded several typical examples. In Glasgow, 
Anderson § reports but 18 cases out of 10,000 consecutive 
cases of skin disease in dispensary practice; and 6 cases in 
1000 cases of skin disease in private practice. In France 
tinea sycosis is without doubt much more common than in 
any other country; at the St. Louis Hospital, Paris, cases 
are of quite frequent occurrence. In Vienna, on the other 
hand, the disease is very seldom encountered. 

It occurs among all classes of men and at all periods of 
life, although more common between the ages of twenty and 
forty than later. It is met with in the weakly and in the 
robust, and does not appear to be in any way dependent 
upon, or influenced by, the state of the general health. 

Pathology. — The fungus finds its way into the hair folli- 
cles, as in the case of tinea favosa, penetrates them deeply, 
and produces its mischief chiefly about the root of the hair. 
Both the follicle and hair become invaded to such an extent 
as to bring about inflammation, followed by more or less 
follicular suppuration and general infiltration of the tissues. 
The irritation caused by the parasite is very great, occasion- 
ing inflammation of the subcutaneous connective tissue, and 
the well-known tubercular formations. This development 

* Boston Medical and Surgical Journal, May 18, 1876. 

f Annual Reports of the Dispensary for Skin Diseases, Boston, 1873, 1874. 

J American Practitioner, May, 1875, and April and May, 1876. 

\ The Lancet, Nov. 11, 1871. 



TINEA SYCOSIS. 



557 



is peculiar to the disease under consideration; it is firm, 
comparatively painless, and manifests but little disposition 
to undergo change, remaining so long as the fungus luxuri- 
ates, finally disappearing gradually without usually leaving 
scars. 




Fig. IX.— Tricophyton, as found in Tinea Sycosis. (300 Diameters.) 
Short, stout hair of beard, with the root sheaths attached to root, showing free 
spores and chains of spores. 

Under the microscope the affected hairs are seen to be 
swollen, at times twisted, and disintegrated about their 
roots. Their bulbs are often obliterated. About their exte- 
rior, especially around the root, and within their structure, 



558 PARASITES. 

the fungus is plainly discernible. The growth shows itself, as 
a rule, abundantly, and consists of both mycelium and spores, 
the spores predominating over the mycelium, as in the case 
of tinea tonsurans, although usually to a less extent. It is 
only occasionally that the spore formation is observed to 
occur so luxuriantly as in tinea tonsurans. (For a description 
of the fungus, see tinea circinata and tinea tonsurans, pathol- 
ogy of.) In hairs which have not been destroyed, mycelium 
may usually be found ramifying over the root, and in the 
root sheaths, which very often come away upon extraction 
attached to the root and bulb of the hair. In other cases 
the fungus is scanty, varying considerably as to quantity in 
different hairs. 

Diagnosis. — Difficulty is occasionally experienced in dis- 
tinguishing between tinea sycosis and sycosis non-parasitica. 
The difference between these affections, however, is usually 
so marked that error can scarcely occur if the distinctive 
features of either be remembered. In tinea sycosis the skin 
and subcutaneous connective tissue are extensively involved, 
as manifested by the induration and the formation of the 
large, characteristic tubercles. In sycosis non-parasitica the 
seat of the process is confined to the hair follicles, the sur- 
rounding as well as the deeper tissues being implicated to 
a comparatively slight extent. The inflammation in sycosis 
non-parasitica is of an active type, and is followed usually 
by free suppuration ; in tinea sycosis it is, as a rule, much 
less active, is deeper seated, and is attended by less suppura- 
tion. The pain, itching, and discomfort of tinea sycosis are 
seldom severe, and almost invariably less so than the appear- 
ance of the disease would indicate. In sycosis non-parasitica 
the throbbing pain and burning sensations are at times so 
severe as to be distressing. The upper lip is rarely invaded 
in tinea sycosis; it is very frequently attacked in sycosis 
non-parasitica. 

The hairs in tinea sycosis are dull in color, dry, swollen, 
often twisted, and brittle; in sycosis non-parasitica they are 
generally healthy in appearance. In tinea sycosis they are 
loose, and may be extracted without pain; in sycosis non- 
parasitica they are, as a rule, firmly seated in their follicles, 



TINEA SYCOSIS. 559 

and cannot be extracted without causing pain. In the latter 
disease, where the suppuration has been very extensive and 
of long standing, they may become detached from their fol- 
licles; but such, in my experience, is only exceptionally the 
case. In tinea sycosis the microscope reveals the parasite, 
the presence of which establishes the diagnosis conclusively. 
(See tinea circinata and tinea tonsurans, diagnosis of.) 

Tinea sycosis bears some resemblance to pustular eczema 
of the face, but the history and course of these diseases are 
ho dissimilar as scarcely to permit of their being confounded. 
Pustular eczema develops itself, as a rule, rapidly, and is 
accompanied with itching, burning, discharge, and crusting. 
The presence of the induration and tubercular formation, 
and the looseness of the hairs, will also serve to distinguish 
it from eczema. 

Tinea sycosis at times resembles the vegetating syphilo- 
derm as it attacks the face in the form of raspberry-like, 
hypertrophic, superficially eroded, moist or crusted papules. 
No true ulceration, however, takes place in tinea sycosis; 
the microscopic examination of the hairs, moreover, together 
with the history, will clear away any doubt that may exist. 

Chronic, circumscribed cases of tinea sycosis, where per- 
haps but one patch exists, may be mistaken for epithelial 
cancer; with attention to the history, course, and clinical 
features of the disease, error is not likely to occur. 

Tinea sycosis is also liable to be confounded with indurated 
acne. It may be known from this affection by its never ap- 
pearing upon the non-hairy parts of the face, as the cheeks and 
forehead, the usual seats of acne. In doubtful cases, where, 
for example, acne shows itself about the neck, the hairs 
should be submitted to the microscope, which will determine 
the presence or absence of the parasite. The hairs are to be 
examined in the manner indicated for tinea tonsurans. 

Treatment.— Depilation and the use of parasiticides are both 
demanded. Where crusts exist, they should be loosened with 
inunctions of almond oil or olive oil, and removed by wash- 
ings with soft soap and warm water, after which shaving 
is to be instituted. Shaving is an important step in the 
treatment, and the sooner it is put into practice the better. 



560 PARASITES. 

The operation should be performed about every other day, 
allowing time between the shaving for the hair to grow suf- 
ficiently to depilate. The process in severe cases is more or 
less painful at first, but in a short time may, with a little 
care, be accomplished with but slight inconvenience; the 
operation is never so painful as one would suppose. The 
advantages gained by shaving are so great as to outweigh 
the slight pain and discomfort occasioned. After the first 
few shavings patients seldom object to continuing with the 
treatment. The face should now again be cleansed with 
soft soap and water, and one of the parasiticides applied. 
The following day depilation is to be performed, in the 
manner described in connection with the treatment of tinea 
favosa. The condition of the hairs will be found to vary ; 
at times they are loose over the whole affected part, and may 
be extracted with ease, while in other cases they are so only 
here and there. Their state depends altogether upon the 
manner in which the parasite has attacked the skin and fol- 
licles, whether superficially or deeply. Shaving and depila- 
tion, upon alternate days, should be perseveringly practiced 
until the new hairs show themselves to be healthy. 

In the choice of a parasiticide one should be guided by 
the stage of the disease, its extent, and the general condition 
of the surface of the skin. A weak or a strong preparation 
may be selected to suit the demands of the case ; for the 
first few days it is well not to employ too stimulating reme- 
dies. Corrosive sublimate, w T ith water or alcohol, one or 
two grains to the ounce, constitutes an excellent lotion, suit- 
able to any stage of the disease; it may also be employed as 
an ointment in the same strength. The yellow sulphate of 
mercury, in the form of an ointment, from fifteen to thirty 
grains to the ounce, may often be used with the best of 
results. Of the milder yet effective remedies, sulphite of 
sodium, as an ointment, or as a lotion, a drachm to the 
ounce; sulphurous acid, one part to two or four of water; 
must be considered as among the most valuable. 

In addition to these remedies, any of those recommeded 
for the other vegetable parasitic diseases may be made use 
of. Whichever the remedy selected, it should be applied 



TINEA VERSICOLOR. 561 

onoe or twice daily in such a manner that it penetrates the 
hair follicles. In the case of a lotion, it should be sopped 
upon the part for ten or fifteen minutes at each sitting; or, 
if one of the milder ointments, it should be slowly and 
thoroughly rubbed in for about the same length of time. 

Prognosis. — The disease is commonly troublesome; two or 
more months will, in the majority of cases, be necessary to 
effect a cure. Relapses are liable to occur if the treatment 
be neglected or discontinued too soon. Shaving should be 
persisted in for several months after all trace of the disease 
has disappeared. 

TINEA VERSICOLOR. 

Syn. Pityriasis Versicolor ; Chloasma (Wilson) ; Mycosis Microsporia •, 
Gtrm., Kleienflechte ; Fr., Pityriasis Versicolor. 

Tinea versicolor is a contagious, vegetable parasitic dis- 
ease, DUE TO THE MICROSPORON FURFUR, CHARACTERIZED BY VARI- 
OUSLY SIZED, IRREGULARLY SHAPED, DRY, FURFURACEOUS, SLIGHTLY 
RAISED, YELLOWISH PATCHES, OCCURRING FOR THE MOST PART UPON 
THE TRUNK IN ADULTS. 

Symptoms. — The disease commences by the formation of 
small, pin-head and split-pea sized, yellowish spots, scattered 
usually here and there over the affected region. In the 
course of a few weeks or months they will have increased 
more or less in size, and will have undergone certain other 
changes, the disease now presenting the following more defi- 
nite characters. As the affection is ordinarily encountered, 
the spots vary considerably in size ; at times they are split- 
pea and finger-nail sized, in other cases much larger. They 
not infrequently unite and form patches which may occupy 
a large surface, as, for example, the greater part of the chest. 
In shape they are at first usually roundish; later, when they 
incline to run into one another, this form is apt to be lost, 
irregularly-shaped patches taking their place. The outline 
of either the early spots or of the larger patches is gener- 
ally sharply defined against the sound skin, more particu- 
larly around that portion of the disease which is spreading 
and encroaching on new territory. The number of the 
lesions varies; there may be but two, three or a half-dozen, 

36 



562 PARASITES. 

or, on the other hand, as is usually the case, a great many. 
They are pale-yellow, buff-yellow, tawny or brownish-yellow 
in color; at times they possess a reddish hue, due to hyper- 
emia; in other cases they have a dirty-yellowish tint. In 
patients who are stout, and in those who perspire freelj*, 
the reddish color of the patches is not infrequently noted. 
Occasionally, in sensitive skins, the patches become the seat 
of considerable irritation and hyperemia, in which case they 
may assume a variegated, whitish and pinkish aspect, and 
may be, moreover, considerably raised. 

In the usual form of the disease, the patches are but 
slightly elevated above the level of the surrounding skin; 
at times so slightly as scarcely to be perceptible. Their 
elevation depends upon the amount of irritation which the 
fungus produces. They are the seat of more or less furfur- 
aceous desquamation, varying with the amount of perspira- 
tion and the degree of scratching to which they have been 
subjected. At times they have a smooth appearance and 
feel, but the scaling may always be detected by rubbing or 
scraping the surface. The scales are very tine, and are of a 
powdery, branny, mealy character. The patches are made 
up entirely of these scales, which, although quite adherent 
to the skin, may be readily scraped away with the finger- 
nail; if the surface be moist, they cohere, cake, and come 
away as a soft, cheesy substance. 

The disease is peculiar in the regions upon which it shows 
itself. Its favorite seats are the chest, abdomen, genitalia, 
axillre, and arms; it is also met with about the neck, on the 
back, and on the thighs. On the other hand, it is never 
encountered on the scalp, face, hands or feet. Practically 
considered, it is a disease of the trunk. It shows no dispo- 
sition to attack those regions which are exposed to the light 
and air. At times, in cases of long standing, the whole 
trunk, from the neck to the groin, the back as well as the 
chest, becomes affected, forming an almost continuous coat- 
ing or sheet of disease. The lesions assume no tendency to 
symmetry, or to any definite arrangement; they are, indeed, 
usually very irregularly distributed, and when extensive and 
in large patches, give to the skin a " mapped" appearance. 



TINEA VERSICOLOR. 563 

Itching, varying, however, considerably in degree, is apt to 
be present. Its seventy depends in a great measure upon 
the activity of the growth. In some cases it is quite marked, 
and gives rise to not a little discomfort; it is, as a rule, more 
pronounced in fleshy persons, and in those who perspire 
abundantly, than in spare individuals. On the other hand, 
cases are not rare in which there is no itching whatsoever^ 
no inconvenience in fact being experienced from the affection 
beyond the disfigurement. 

Its course is variable; at times it spreads rapidly, in other 
cases slowly. It is, as a rule, a persistent disease. With- 
out appropriate treatment it may continue for an indefinite 
period; examples are not uncommon where the parasite has 
flourished for fifteen or twenty years. Relapses are of not 
infrequent occurrence, even in those cases where the treat- 
ment has been judicious. 

Etiology.— The cause of the disease is found in the pres- 
ence upon the surface of the skin of a vegetable growth, 
called the Microsporon Furfur. It was discovered by Eich- 
stedt, of Greifswald, in 1846.* 

The affection is contagious, although so only in a low de- 
gree, and under peculiar conditions. Cases are occasionally 
met with in which it has been communicated from husband 
to wife, and vice versa; also from sister to sister, and from 
brother to brother, particularly where they have occupied 
the same bed. Such instances, however, are exceptional; 
as a rule, it does not show itself in more than one mem- 
ber of a family. Its contagious properties are feeble, differ- 
ing in this respect from the other vegetable parasitic affec- 
tions. It is usually met with upon persons between the ages 
of twenty and forty; it seldom, if ever, occurs before puberty 
and rarely after fifty; I have never observed it in children. 
Both sexes are about equally affected. 

The general health of those attacked is, as a rule, good. 
The disease does not appear to be in any way dependent 
upon a state of ill health. The individuals are very often 



* Froriep's Xeue Xotizen aus dem Gebiete der Xatur- und Heilkunde, Bd, 
xxxix., p. 270. 



564 PARASITES. 

stout, well nourished, and, otherwise, in perfect health. It 
attacks the rich as w r ell as the poor, and bathers as well as 
those who rarely bathe. 

Tinea versicolor is a common affection. It is encountered 
in all parts of the world, although there is considerable varia- 
tion in the frequency of its occurrence in different countries 
and places. Wilson,* in London, records 131 cases out of 
10,000 cases of skin disease met with in private practice; 
Anderson,f in Glasgow, only 106 cases out of 10,000 cases 
of skin disease in dispensary practice. In our own country, 
White, I in Boston, reports 13 cases in 1000 cases of skin 
disease in private practice, and 14 cases out of 1000 cases 
among dispensary patients. Bulkley§ gives similar figures 
for New York, he having encountered but 14 cases out of 
1617 cases of skin disease in dispensary service. In Phila- 
delphia, on the other hand, the disease is without doubt of 
more frequent occurrence than in any of the above-named 
cities ; at the Dispensary for Skin Diseases, 33 cases were 
recorded out of 1267 consecutive cases of skin disease; at 
the clinic for diseases of the skin at the Hospital of the 
University of Pennsylvania, 21 cases were observed amoug 
1205 consecutive cases of skin disease. In India and in 
the Eastern countries generally the affection is exceedingly 
common. 

Pathology. — The microsporon furfur consists of mycelium 
and spores. The mycelium is made up of a great number 
of line, slender, variously sized, for the most part short 
threads, which cross one another in all directions, forming 
an irregular, more or less intricate network. The th reads 
vary considerably in their form; they are straight or curved, 
stick-shaped, jointed and angular, twisted or looped, fork- 
shaped, or crooked and wavy. They are simple and empty, 
or contain here and there spores and granules; the spores, 
often quite large, are particularly conspicuous about the 
joints. The ends of the threads are, moreover, often found 

* Journal of Cutaneous Medicine, vol. iii. No. 11. 

f The Lancet, Nov. 11, 1871. 

X Third Annual Eeport of State Board of Health of Mass. Boston, 1872. 

J American Practitioner, May., 1875, and April and May, 1876. 






TINEA VERSICOLOR. 



565 



tipped with single spores. The diameter of the mycelium 
varies from xtW (.001512 mm.) to ^'" (.003848 mm.). 

The spores are small, variously sized and shaped (as in the 
case of the achorion Schonleinii), round, ovalish or irregu- 
larly rounded, highly refractive, grayish or pale-greenish 
bodies, with or without nuclei, having a marked tendency to 
aggregate and crowd together here and there in groups or 
clusters. This arrangement is peculiar; it does not occur 
in connection with any of the other vegetable parasites. 




Fig. X.— Micros poron Furfur. (500 Diameters.) 
Showing mycelium in various stages of development, groups of spores, and free spores. 

Large numbers of spores, closely packed, are often present 
in these masses. Free spores are also met with everywhere 
over the field. Their size varies considerably; they measure 
from *V" (.002351 mm.) to W (-008466 mm.). The 
growth is found in every stage of development from myce- 
lium to spore, and with a sufficiently high power (500 to 
800) presents even more varied forms than the achorion 
Schonleinii. (See Fig. X.) 

The fundus, both mvcelium and spores, is luxuriant, and is 



56(5 PARASITES. 

always present in such abundance that no difficulty can arise 
in discovering it. Its habitat is in the horny layer of the 
epidermis, which it permeates to such an extent as to take 
complete possession of it. It is the most superficial ly-seated 
of all of the vegetable parasites of the skin. It does not 
invade either the hair or the nail. It gives rise to no marked 
inflammatory symptoms; where there is much irritation, 
however, a high degree of hyperemia not infrequently 
manifests itself. 

The fungus at times grows with great vigor; in other cases 
it seems barely able to sustain itself. As a rule, it is not 
tenacious of life, and may be destroyed without difficulty by 
any one of the numerous substances which exert a destruc- 
tive influence upon vegetable organisms. 

Diagnosis. — In the majority of cases no difficulty will be 
experienced in recognizing the disease. At the same time, 
examples occasionally present themselves where, from some 
peculiarity in the shape, size, coloration or localization of 
the patches, the true nature of the affection is not enter- 
tained. If the patch, however, be but suspected of being 
parasitic, there can remain no doubt as to its character, for 
the microscopic examination of the scales will establish the 
presence of the fungus. The mode of making the exami- 
nation is simple. A few of the scales are scraped from the 
surface with a blunt knife-blade or with the finger-nail, and 
placed upon a glass slide with a drop of dilute liquor potassa?, 
and covered with a thin glass cover. The specimen may 
be at once submitted to the microscope, a power of from 
300 to 500 diameters being necessary to show the fungus to 
advantage. It ma}% however, be detected with a lower power 
(200). No trouble whatever will occur in finding the growth, 
for it is always very abundant. 

The seat of the affection, almost invariably upon the 
trunk, especially about the chest and abdomen ; the yellow- 
ish or brownish color, and the furfuraceous desquamation 
of the patches, are also to be borne in mind. If a patch 
be rubbed or scratched with the finger-nail, the scales will 
fall in the form of a fine dust or powder; or, if the surface 
be moist from perspiration or other cause, the epidermis 



TINEA VERSICOLOR. 567 

will cake and form into rolls. Beneath the scales the skin 
will appear pinkish or reddish, according to the amount of 
irritation. 

Care must be observed not to confound the disease with 
vitiligo, an affection of an entirely different nature, but one, 
nevertheless, which at times closely resembles tinea versi- 
color in some of its general features. Vitiligo is an affection 
of the pigmentary system of the skin, whose seat is confined 
to the mucous layer of the epidermis ; in tinea versicolor the 
process, it will be remembered, is seated in the horny layer 
of the epidermis. If a patch of vitiligo be scratched with the 
finger-nail, no scaling will take place, for the horny layer of 
the epidermis is normal ; while, on the other hand, if the 
case be one of tinea versicolor, considerable desquamation 
will occur. This simple test, therefore, is all-sufficient to 
establish the diagnosis. 

Another disorder of the pigmentary system which may 
be mistaken for tinea versicolor, is the affection known as 
chloasma. Here the process, as in vitiligo, consists in an 
anomaly of the pigment deposit of the skin, and is conse- 
quently seated in the mucous layer of the epidermis. Chlo- 
asma, moreover, as a rule, does not occupy the same regions 
as tinea versicolor; it is usually encountered about the face, 
a region never attacked by the disease under consideration. 

Certain cases of the erythematous syphiloderm may pre- 
sent a likeness to the small, rounded patches of tinea versi- 
color often met with; but error in diagnosis can scarcely' 
occur if attention be paid to the characteristic features of 
the parasitic disease. It must be. stated, nevertheless, that 
tinea versicolor is not infrequently confounded with the ery- 
thematous syphiloderm; such cases are certainly not rare in 
practice. 

In tinea versicolor, the yellowish or brownish color, the 
variable size and shape and the scaly surface of the patches, 
their course, and their seat, are all to be borne in mind. In 
syphilis the patches are usually indistinct in outline; are 
seldom larger than a finger-nail; present a more mottled 
appearance; are pigmented; are but very slightly if at all 
raised ; are not surmounted with furfuraceous scales ; do not 



5b8 PARASITES. 

itch ; and, finally, are apt to occur upon the face, limbs, 
hands and feet as well as upon the trunk. The diagnosis 
may always be definitely established by the microscope. 
The pigmentary syphiloderm is so peculiar and so rare, that 
it is not likely to be confounded with the disease under con- 
sideration. As a word of caution, it must not be forgotten 
that tinea versicolor is quite as liable to show itself upon 
a syphilitic as upon a non-syphilitic person ; the fact of an 
individual being syphilitic by no means precludes the possi- 
bility of contracting a vegetable parasitic disease. 

Strange as it may sound, I have known cases where the 
patches of tinea versicolor have been regarded as the macu- 
lar manifestation of leprosy; such a gross error, however, it 
need scarcely be remarked, is not likely to occur with one 
at all familiar with either disease. 

Treatment. — The treatment is simple, and is followed by 
the most satisfactory results. A parasiticide of one kind or 
another, properly and thoroughly applied, is all that will be 
found necessary for the complete removal of the disease. In 
the choice of a remedy care should be exercised in selecting 
one of suitable strength, and at the same time one which 
may be conveniently applied by the patient. It should be 
remembered that the affection is one, as a rule, readily 
amenable to treatment, and that consequently strong prepa- 
rations are not called for. 

Strict attention to personal cleanliness should in all cases 
be enjoined. Frequent washings with soft soap and cold 
water are often alone sufficient to effect a cure in mild 
cases, where the parasite has a feeble hold upon the skin. 
Alkaline baths, consisting of two or three ounces each of 
carbonate of sodium and potassium to thirty gallons of water, 
are also useful in light cases where the disease is diffused 
over a considerable surface. 

Repeated rubbings with soft soap, after the method prac- 
tised in the Vienna General Hospital, by Hebra, constitute 
a ready and useful treatment. It may be directed as follows : 
a piece of sapo viridis the size of a walnut or larger, ac- 
cording to the amount of surface to be treated, is to be 
rubbed into the affected skin, in a thorough manner, every 



TIXEA VERSICOLOR. 569 



morning and evening for live or six days, one coating of 
soap being applied over the other. The patient during the 
period of these rubbings should not be permitted to bathe 
nor to wash the parts. Four or live days are now allowed 
to elapse, when the first bath is ordered, after which the 
disease will be observed in many cases to have disappeared 
entirely. If certain patches still remain, the same course may 
be repeated, or the frequent use of soft soap in connection 
with the plain cold bath relied upon to complete the cure. 

Excellent results are also obtained from the employment 
of ointments and lotions containing sulphite of sodium, to 
be used twice daily. Both ointment and lotion may be pre- 
pared in the strength of one drachm to the ounce of simple 
ointment or of water. Sulphurous acid is also a valuable 
remedy; it should be diluted with two or more parts of water, 
and applied as a lotion morning and evening. Before using 
these preparations, it is well to have the surface washed and 
cleansed with water and soft soap. Corrosive sublimate will 
also be found serviceable in the form of a lotion, two or three 
grains to the ounce. Anderson* gives the following formula, 
of which he speaks well : 

R Hydrargyri Chloridi Corrosivi, ^i ; 

Saponis Yiridis, ^ii; 

Alcoholis, f^iv ; 

01. Lavandulae, f^ii. 
M. 

This is to be well rubbed into the affected parts night and 
morning. 

Whatever remedy be employed, it is proper to continue 
treatment with one of the milder preparations for several 
weeks after all symptoms have disappeared, to guard against 
relapses, which are liable to occur if this precaution be not 
exercised. 

Should the patient manifest signs of general ill health 
and the disease prove intractable, in the form of repeated 
relapses, internal remedies, as may seem indicated, may at 
times be resorted to. 

Prognosis.— This is always favorable. For an ordinary 

* Parasitic Aflections of the Skin. Second edition, London, 1868. 



570 PARASITES. 

case, two or three weeks are usually sufficient to bring 
about a cure, although much will depend upon the manner 
in which the applications are made; if carelessly employed, 
a longer time will often be necessary. As a rule, the disease 
is very amenable to treatment. The patient should in all 
cases be warned against the possibility of a relapse. 

SCABIES. 

Syn. Itch ; Germ., Kratze ; Fr., Gale. 

Scabies is a contagious, animal parasitic disease, due to the 
sarcoptes scabiei, characterized by the formation op cuniculi, 
papules, vesicles and pustules, followed by excoriations, 
crusts and general cutaneous inflammation, accompanied with 

ITCHING. 

Symptoms. — Inasmuch as the disease presents a very differ- 
ent appearance as it is seen in its early or its later stage, it 
will be necessary to describe its course from the date of con- 
tagion. The itch mite no sooner finds itself upon the skin 
than it begins its work of burrowing; and here it may be 
mentioned that it is the female only which penetrates be- 
neath the epidermis. Once within the skin, a burrow, or 
cuniculus, is rapidly formed, in which numerous eggs are 
deposited, and which, moreover, serves as a habitat for the 
female during her life. The male is said never to enter the 
skin, but to live upon the surface. According as the mite 
penetrates superficially or deeply, and according to the sus- 
ceptibility of the skin, will one or another lesion be pro- 
duced. After a certain time from the date of contagion a 
variable number of mites will have been hatched forth, all 
of which at once begin to care for themselves and to bur- 
row. Thus the early symptoms of the disease nre manifested 
by the presence of a source of irritation at various points, 
characterized by the formation of minute inflammatory 
puncta, papules or vesicles. If the parts be now carefully 
examined here and there the beginning of a cuniculus 
may usually be seen, although at this stage of the disease 
these will scarcely have been formed to any extent. The 
lesions may be either confined to a small area or quite gen- 



SCABIES. 571 

eral ; they may exist upon the hands alone, the parts of the 
body usually first invaded, or they may be distributed over 
various regions. They increase rapidly, and in the course 
of a fortnight or three weeks the disease generally appears 
typically developed. The symptoms now consist of distinct 
cuniculi, numerous small papules, distended vesicles and pus- 
tules, varying in size, excoriations, scratch marks, fissures, 
torn vesicles and pustules with crusts and bloodcrusts, all 
seated upon a more or less acutely inflamed skin. Not one 
or two but a number of lesions, it will be seen, go to make up 
the picture of scabies as it exists when fully developed. It 
is, indeed, by this multiform character of the lesions that the 
affection is best known. 

The disease spreads day by day, until finally, in the course 
of a month or six weeks, the whole cutaneous surface is 
involved, certain regions of the body always suffering more 
markedly than others, showing at times a very extensive in- 
flammation of the tissues. The older the scabies the greater 
will be the cutaneous disturbance, although by no means 
the more distinct the characteristic lesions, for these after a 
time become almost unrecognizable amid the crusts and ex- 
tensive excoriations with which the parts are covered. 

Having thus described the general course of the disease, 
it is in place to refer to the individual lesions. The burrow, 
furrow, or cuniculus, as it is variously termed, is formed by 
the mite entering the skin and making its way just beneath 
the horny layer of the epidermis, which is raised very much 
as a mole undermines the ground. It is to be seen as a 
slight linear elevation of the epidermis, varying from half a 
line to four or five lines in length, one or two lines represent- 
ing the average length. It is usually irregular and tortuous in 
its course. In color it is whitish or yellowish, with a dotted, 
speckled look, or blackish, varying with the occupation of 
the patient and the amount of dirt which has collected upon 
the surface. At either end it terminates abruptly, exhibit- 
ing usually darkish points; the more prominent and usually 
lighter of these represents the mite, which lies imbedded 
in° the mucous layer of the epidermis. Burrows, such as 
just described, are commonly seen only about the fingers, 



572 PARASITES. 

for upon other parts of the body they become torn and 
scratched before they have had time to arrive at any length. 

The papules, vesicles and pustules are peculiar, and differ 
in their appearance and course from those observed in other 
diseases. All of these lesions may usually be seen at the same 
time, in various stages of development. The papules are 
usually numerous, always small, and are the first lesions to 
make their appearance. Very often the disease does not get 
beyond the papular stage. The vesicles may be either minute 
or quite large; they are ordinarily observed of various sizes 
and shapes. They usually have an inflamed base, and stand 
forth prominently. Upon their tops, short cuniculi are very 
often seen, beneath which, in recent lesions, the itch mite 
may usually be found. This is a characteristic mark of the 
scabies vesicle ; it also exists in the pustule. The vesicles 
may remain or they may pass into pustules, which, if not 
disturbed, may increase to the size of split peas and larger. 
When large they are apt to be more or less irregular in out- 
line. They show no regularity of distribution. 

The scratching of the patient produces secondary lesions, 
which play a very important part in the disease. These 
scratch marks consist of excoriations of various kinds ; torn 
papules, vesicles and pustules, lacerations of the epidermis 
and corium, and wounded hair follicles, being among the 
most conspicuous. Crusts, composed of blood, serum and 
pus, of all forms and sizes, follow these lesions, and are 
usually present in quantity. The amount of matter of this 
kind will depend upon the length of time the scabies has 
existed, as w r ell as upon the natural susceptibility of skin and 
the degree of scratching indulged in by the patient. 

Lastly, the general cutaneous inflammation, or dermatitis, 
accompanied by infiltration, thickening and pigmentation, is 
to be taken into consideration. As a rule, all of the symptoms 
referred to are present at the same time, and it will be seen 
that great tissue disturbance must necessarily be present. As 
just remarked, however, this varies, according to the natural 
sensibility of the tissues, general nutrition and health of the 
individual, mechanical irritation in the form of injudicious 
treatment, scratching and other circumstances. 



scabies. 573 

The regions of the body attacked are characteristic. The 
affection usually begins about the hands, and especially the 
lingers. The wrists, penis in the male, and mammas in the 
female, are generally next invaded, followed by more or less 
eruption about all of the softer tissues of the trunk. The 
sides of the fingers and the various folds where they join the 
hands are the particular localities attacked. In the male, 
the penis, owing to frequent contact with the hands for the 
purpose of urinating, is almost invariably affected. In the 
female, the mammae, notably around and upon the nipples, 
usually show marked signs of the disease. The umbilicus, 
axillae and buttocks in both sexes are commonly invaded. 
The lower limbs are seldom involved to any great degree, 
except in cases of long duration; the toes, however, particu- 
larly in children, are often the seat of the trouble. 

Thus far only the objective symptoms have been referred 
to ; there remain to be referred to those of a subjective 
nature, characterized mainly by itching which is always 
present in a greater or less degree. It commences as soon 
as contagion has taken place, gradually increasing in inten- 
sity until it becomes quite severe. It varies greatly, how- 
ever, with the susceptibility of the skin, as well as with the 
temperament of the individual. It is constant, but usually 
very much aggravated at night; sometimes it is felt only 
very slightly through the day. 

In those predisposed to eczema, this disease, in addition 
to the simple dermatitis, is provoked by the itch mite in the 
same manner as by any other penetrating irritant; hence in 
countries where scabies is common, examples of the disease 
combined with true eczema are by no means rare. The com- 
plication is always troublesome, both on account of the dif- 
ficulty of diagnosis as well as the treatment. On the other 
hand, where the patient possesses no disposition to the de- 
velopment of eczema, a simple dermatitis results, charac- 
terized by the lesions already specified, and which invariably 
terminates in more or less rapid recovery as soon as the 
cause has been removed. 

Scabies sometimes continues a very long while, not infre- 
quently years, before it is either detected or cured, in which 



574 PARASITES. 

case the symptoms just detailed are all greatly exagger- 
ated.* 

Etiology. — There is one cause only of the disease, namely, 
the presence of the sarcoptes scabiei. None are exempt from 
its ravages. It attacks all individuals indiscriminately wher- 
ever the opportunity of burrowing itself into the tissues is 
offered. The affection arises from contagion, and only from 
contagion. This may be direct or indirect ; the former when 
the mite is transferred directly from one person to another, 
as by a shake of the hand ; the latter when it occurs through 
the medium of something which for the time holds the mite, 
as, for example, the bedding or the clothes. Secondarily, 
very much of the disease which exists is caused by the 
scratching of the patient. 

Scabies occurs in persons of all ages, from infancy to old 
age, as well as in those in every walk of life ; although on 
account of inattention to cleanliness, the wearing of the same 
underclothes for a long time, and the more frequent sources 
of contagion to which the poor are necessarily subjected, it 
is of much more frequent occurrence among this class. It 
is commoner in men than in women, from the fact that men 
among the lower orders are more apt to sleep together than 
women. 

Scabies exists very much more extensively in some com- 
munities than in others. It is the most common of all 
cutaneous diseases in the various countries of Europe. In 
Glasgow, according to the statistics of Anderson, f it is of 
unusually frequent occurrence, 2527 cases having been en- 
countered among 10,000 consecutive dispensary cases of skin 
disease, and 44 cases out of 1000 cases in private practice. 
In London, Mr. WilsonJ reports 308 examples among 10,000 
cases of cutaneous disease, as observed in private practice. 
In both Paris and Vienna scabies is exceedingly common, 
more so in the first named city. 

* The so-called " Norwegian Scabies" may be cited as an example. Here 
the disease has often lasted a lifetime, the whole body being in a chronically 
inflamed state, and covered with pustules, extensive crusts and debris. 

f The Lancet, Nov. 11, 1871. 

J Journal of Cutaneous Medicine, vol. iii., No. 11. 



SCABIES. 



575 



In the United States, at the present time, it is quite rare, 
varying considerably, however, in the frequency of its occur- 
rence in the different large cities. It is more prevalent in 
seaport than in inland towns. White,* of Boston, reports 
139 cases among 5000 consecutive cases of skin disease, as 
met with at the out-door department of the Massachusetts 
General Hospital. Wigglesworth,f at the Dispensary for 
Skin Diseases, Boston, records but 13 cases out of 1339 con- 
secutive cases of skin disease. In New York, the disease is 
encountered more frequently; BulkleyJ gives 62 cases in 
1617 cases of skin disease, as observed in dispensary prac- 
tice. In Philadelphia, at the Dispensary for Skin Diseases, 
there were but 9 cases out of 1267 consecutive cases of skin 
disease; while at the clinic for cutaneous diseases at the 
Hospital of the University of Pennsylvania, only 3 cases 
were encountered among 1205 consecutive cases of skin 
disease. 

During the period of the late civil war the disease was 
quite prevalent throughout our country. The so-called 
" army itch" possesses no peculiarities worthy of remark, 
and hence is to be viewed simply as ordinary scabies. 

Pathology. — Under this head may be described the anatomy 
of the mite, its habits of life, its habitat, and the lesions to 
which it gives rise. The sarcoptes scabiei (termed also sar- 
coptes hominis and acarus scabiei) is a minute insect, barely 
visible to the naked eye as a yellowish-white, rounded body. 
The female is usually met with, the male, in all probability, 
taking no part in causing the cutaneous lesions, and for this 
reason being very rarely encountered. The adult female is 
seen under the microscope to have a rounded ovalish body, 
convex on the back and flat on the belly, marked with two 
slight indentations on either side, and numerous transverse, 
undulating lines running over its ventral surface. (See Fig. 
XL) On the back are rows of conical, teeth-like prominences, 
or spines, with on either side of the posterior part of the body 

* Boston Medical and Surgical Journal, Jan. 27, 1876. 
f Annual Reports of the Dispensary for Skin Diseases, Boston, for 1873 and 
1874. 

X American Practitioner, May, 1875, and April and May, 1876. 



576 



PARASITES. 



a series of larger, spike-shaped processes. The head is small, 
of a rounded oval shape, and is closely set in the body; 
it is a complex structure, made up of palpi and mandibles, 
and is provided with six small hairs. Eyes do not exist. 
The legs are quite conspicuous and are eight in number, 
four being situated close to the head, and four posteriorly. 
The four front legs are short, stout, conical or teat-shaped, 
jointed bodies, and are provided with stalked, cup-shaped 
suckers : hairs also come out from the extremities and sides 




Fig. XI. — Saucoptes Scabiei. (125 Diameters.) 
Female. Ventral surface. 



Fig. XII. — Svrcoptes Scabiei. (125 Diameter?. 
Male. Ventral surface. (After Lanquetin.*) 



of these structures. The hinder legs come off from the pos- 
terior half of the middle of the body, are less bulky than 
the front legs, and are each armed at their extremities with 
a long, curved bristle. In addition to the legs, there are 
bristles which come off from the body, two on either side 
and four posteriorly. The female is much larger than the 
male (almost twice the size), and varies from \ tn (.3022 mm.) 
to \"' (.4233 mm.) in length, and from \>" (.2645 mm.) to £"' 
(.3527 mm.) in breadth. The male in general structure 



* Notice sur la Gale et sur l'animalcule qui la produit. Avec planches 
gravees. Seconde edition. Paris, 1859. 



scabies. 577 

differs bat little from the female; the last pair of posterior 
legs, however, are provided with stalked suckers in the place 
of bristles as in the female; the organs of generation, more- 
over, are quite conspicuously marked. (See Fig. XII.) The 
young, or larvae, of either sex, may be recognized by their 
possessing but two hind legs.* 

The female finds her way by boring in a perpendicular 
direction through the horny layer into the mucous layer of 
the epidermis, and, being impregnated, begins at once laying 
her eggs and at the same time making her burrow. A vari- 
able number of eggs are deposited, usually about a dozen, 
after which the mite perishes in the skin. They average 
T V" (.1764 mm.) in length. If a cnniculus be carefully ex- 
cised with a sharp knife or flat scissors, and placed beneath 
a microscope, it will be found to contain the mite, with 
usually from ten to fifteen eggs, arranged in a row, egg- 
shells, more or less broken, and small, roundish, dark-colored 
specks, — the excrement. The ova hatch out in eight or ten 
days. 

The female may be captured by puncturing the blind end 
of one of the longer burrows (at which end the mite will 
always be found, appearing as a whitish or dark point) with 
a pin or needle. With a little practice no difficulty will be 
experienced in securing the prize. Before the operation is 
attempted, however, care should be observed in ascertaining 
the exact seat of the mite. 

Scabies must be viewed as an artificial inflammation of 
the skin. It is brought about by the peculiar ravages of 
the insect, together with the scratching on the part of the 
patient. The lesions produced, both primary and secondary, 
with the exception of the burrows, are very similar, from an 
anatomical point of view, to those encountered in certain of 
the varieties of eczema. The amount of cutaneous disturb- 
ance varies considerably ; as a rule, it is marked, the degree 
of inflammation depending upon the duration of the disease, 

* For a complete treatise on the anatomy of the sarcoptes scabiei, see the 
superb and elaborate monograph of M. H. F. Fiirstenberg, entitled " Die 
Kratzmilben der Mensehen und Thiere, mit 15 lithographirten Taflen, 10 
Umrissfiguren und 3 Holzschnitten. Leipzig, 1831." 



578 PARASITES. 

and, more particularly, upon the sensibility of the skin. 
With this latter point will rest not only the grade of inflam- 
mation, but also the amount of scratching, a most important 
feature in the course of the disease. According as the skin 
is or is not sensitive, will the disease prove comparatively 
light or severe in type. In cases where there is a predis- 
position to eczema, this disease will undoubtedly be called 
forth, seriously complicating the course of the original affec- 
tion ; such instances are sufficiently common in countries 
where scabies is of frequent occurrence.* In the majority 
of cases, however, no condition worthy of the name of ec- 
zema is present. 

Diagnosis. — Bearing in mind the various points which de- 
note the presence of the disease, the diagnosis, as a rule, is 
easy. At the same time it must not be forgotten that the 
affection is liable to be encountered in all stages, from the 
day of contagion to the period of its highest development, 
and that the symptoms vary greatly according to its age, the 
influences to which it has been exposed, and other circum- 
stances. 

The presence of the burrow suffices for the diagnosis, and 
should be looked for as soon as the trouble is suspected; but 
it is by no means always to be found. In the flrst stage of 
the affection typical burrows do not exist, for a certain length 
of time is required for the mite to produce them ; after the 
disease has continued for some time they become, on the 
other hand, in a great measure obliterated by the scratch- 
ing of the patient or by strong applications. Thus it will 
be seen that their demonstration may prove a matter of dif- 
ficulty. Their remains, however, in old cases may always 
be noticed. The mite itself may usually be extracted with 
a pin from a recent vesicle or burrow; but failure in this 
direction should by no means carry weight in the diagnosis, 
for it requires sharp eyes and a certain amount of dexterity 
to capture the intruder, even when in full sight. Moreover, 

* In this country it is rare, in mj -experience, to see true eczema caused by 
scabies. The affection, as a rule, disappears rapidly upon the employment of 
a suitable parasiticide, a result which could .not be looked for were eczema 
present. 



scabies. 579 

the supposed burrow may upon closer inspection prove to be 
but a line of abraded epidermis, more or less filled with dirt 
or other extraneous matter. They are not always plain to be 
seen ; at times they are rendered obscure by the occupation 
of the patient, as, for example, in bakers and in blacksmiths. 
They are most numerous and marked where the skin is thin 
and protected from external influences. In the majority of 
cases they are to be readily detected only upon the sides of 
the lingers. 

The region of the body affected must always point strongly 
to scabies. The hands, wrists, fore-arms, the penis in the 
male, the mammae and nipples in the female, the buttocks in 
both sexes, particularly in children, and the trunk, are all 
more or less involved. The face and scalp remain free, ex- 
cept in the case of infants. 

The multiformity of the eruption, where the disease is 
well developed, consisting of a generally inflamed surface, 
papules, vesicles, pustules, scratch marks, excoriations, crusts 
of blood and pus, should in itself lead to a suspicion of the 
disease, especially if it occur upon the parts just specified. 
Scabies may, indeed, usually be recognized by the general 
picture which it presents. To corroborate the diagnosis, a 
history of contagion will in the majority of cases be fur- 
nished by the patient. 

There are, nevertheless, several diseases with which it may 
be confounded. It is most liable to be mistaken for vesicular 
and pustular eczema, with which it has many symptoms in 
common. As has been already stated, the two diseases may 
exist together as a complication, but such an occurrence is 
rare. The presence of the mite, the burrows, the acumi- 
nated, more or less isolated vesicles and pustules, with irregu- 
lar dots or lines in their roofs, the regions affected, the gradual 
accession in the severity of all the symptoms, the steady in- 
crease day by day of itching and consequent scratching, and 
lastly, the proof of contagion, all speak strongly in favor of 
scabies and directly against eczema. 

The affection may be distinguished from phtheiriasis by 
the character of the anatomical lesions, as well as by the 
regions involved. Finally, it is to be remembered that 



580 PARASITES. 

scabies may exist intercurrently, in connection with various 
skin diseases. 

Treatment. — Once recognized, the disease is speedily cured. 
External means alone are required. Before prescribing, how- 
ever, there are several points which should always be taken 
into consideration. The age of the patient, whether an infant, 
child or adult, is a matter of some importance in deciding 
upon the remedy to be used. The natural sensitiveness of 
the skin, whether delicate and fine or coarse and harsh, 
should also be determined. A knowledge of the duration of 
the trouble, as well as the amount of secondary disturbance in 
the form of excoriations, crusts, and infiltration which may 
exist, is likewise important. If of some weeks' standing, 
accompanied by extensive vesiculation, pustulation, excoria- 
tion, and crusting, with marked inflammation and irritability 
of the whole surface, the treatment should at first be mild. 
If, on the other hand, of recent date, unaccompanied by 
marked secondary products, a more vigorous method may 
be ordered and the cure hastened. 

The objects to be gained in the treatment are twofold, 
namely, the destruction of the parasite and at the same 
time relief to the inflamed skin. Ordinarily, the artificially- 
disturbed tissues recuperate very rapidly after the destruc- 
tion of the mite, so that no special remedies are demanded 
for this condition. If eczema, however, exist in connection 
with the scabies, or if the case be a very severe one of long 
duration, it is usually weeks or longer before complete re- 
covery takes place. 

Sulphur, in one form or another, is the remedy which may 
be relied upon in all cases. It is best employed as an oint- 
ment. The strength should vary somewhat with the case at 
hand, for, although a very valuable parasiticide, if used too 
strong, where there is a high degree of inflammation, it acts 
also as au irritant to the skin. A drachm to the ounce of 
simple ointment will be found suitable for the majority of 
cases; in children, a half drachm to the ounce will prove of 
sufficient strength. 

Before applying any one of the sulphur ointments, the 
patient should receive a thorough washing with soft soap 



SCABIES. 581 

and water, to be followed if possible by a warm bath of 
half an hour's duration. After this the ointment should be 
firmly and slowly rubbed into every portion of the body 
(except the head in the case of an adult), special attention 
being devoted to the hands, fingers and other parts usually 
the seat of the disease. About an ounce of the ointment 
should be consumed for each application. The rubbings are 
to be repeated every evening for three clays, at the expira- 
tion of which time a bath with soap may be taken. Should 
this not suffice to cure the trouble, the frictions may be again 
undertaken, and continued for a day dr two longer, which 
in all cases will terminate the disease. The itching will 
usually abate considerably after the first day, although it 
will not cease entirely until some days have elapsed after 
the destruction of the parasites, owing to the general cuta- 
neous inflammation and irritation which always exist. The 
applications, therefore, are not to be persisted with because 
the itching continues, but should be stopped after the third 
day, at least until it be ascertained whether or not the mites 
have been destroyed. Concerning this point discretion must 
be used, for much harm may result from too oft repeated 
inunctions. 

Balsam of Peru, in itself a parasiticide, may be advanta- 
geously combined with sulphur, constituting an excellent 
preparation for children, as in the following formula : 

R Sulphuris Sublimati, ^ss ; 

Balsumi Peruviani, £ss ; 

Adipis, gi. 
M. Ft. ungt. 

Styrax, also a balsam, is likewise a valuable remedy. It is 
well spoken of by Anderson,* and is by him even preferred 
to sulphur; he employs it according to the appended pre- 
scription : 

R Styracis Liquidi, %i; 

Adipis, ^ii. 
Liquefac et cola. 

It possesses the advantages of having a pleasant odor, 
of being clean, and, moreover, unirritating to the skin. 



* Treatment of Diseases of the Skin. London, 1872. 



582 PARASITES. 

Tar, oi! of cade, sapo viridis, carbonate of potassium, lime, 
petroleum, the essential oils, and staphisagria, are also all 
successfully employed, with or without sulphur, in various 
combinations. They constitute the principal ingredients of 
numerous well-known prescriptions, some which have had 
considerable repute in the treatment of this disease. A few 
of these only need be referred to : 

B Potassii Carbonatis, 31 ; 

Sulphuris Sublimati, ^ii ; • 

Adipis, ^iss. 
M. Ft. ungt. 

This is Hardy's modification of Helmerich's ointment, 
and is the preparation used at the St. Louis Hospital, Paris. 
The patient is well rubbed with sapo viridis for half an hour, 
when he is placed in a warm bath, and permitted to remain 
there another half hour, after which the above ointment is 
thoroughly rubbed into the skin, and the cure thus com- 
pleted. This course of treatment, though rapid, and as a 
rule effectual, is at the same time somewhat irritating to 
the skin ; it was first instituted by Hardy, and, for a large 
hospital service, fulfils its purpose.* 

Wilkinson's ointment, as modified by Hebra, is a prepa- 
ration much in vogue in the Vienna General Hospital; the 
following is Hebra's formula: 

R Sulphuris Sublimati, " 

Olei Cadini, aa^iii ; 

Creta? Prseparatee, 3H ; 

Saponis Viridis, 

Adipis, aa^i. 
M. Ft. ungt. 

Patients are rubbed morning and evening for two days, 
after which nothing is done for a week, when, for the first 
time, a warm bath is ordered, and the treatment concluded. 
The preparation, though efficacious, is by no means elegant; 
it is more suitable for hospital than for private practice. 

The patient should always be cautioned concerning the 

* At the St. Louis Hospital, Paris, the number of scabies patients is very 
large; not infrequently as many as forty or fifty new eases per day apply for 
treatment. They are not admitted into the hospital, but receive the cure 
described in a department devoted to this purpose. 



leptus. 583 

contagions nature of the disease. It is advisable to wear 
the same underclothes during the treatment, and afterwards 
to have them boiled. 

Prognosis. — This is always favorable, a week usually suf- 
ficing for the cure where the disease is not of long stand- 
ing. If marked secondary lesions exist, several weeks or 
longer may be necessary to restore the skin to complete 
health. Relapses occur only in cases where the treatment 
has been imperfectly carried out; or, where the individual 
has re-contracted the disease. 

Leptus. — Two species of leptus which are known to attack 
man are described by Prof. Riley,* of St. Louis, as occurring 
in the United States, both of which are sufficiently common 
in our southwestern states. 

Leptus American us, or American Harvest Mite. — This is 
a minute (barely visible to the naked eye), active, brick-red 
colored, elongate pyriform creature with six long legs. It 
is found (more frequently, it is said, upon children than upon 
adults) upon the scalp, in the axilla?, and on other parts of 
the body. It does not completely bury itself in the flesh, 
but insinuates the anterior portion of the body only beneath 
the skin, causing a small inflammatory papule. 

Leptus Irritans, or Irritating Harvest Mite.f — This is the 
better known of the two, and differs from the preceding 
merely in having a roundish oval form. It gives rise to 
considerable trouble, burying itself in the skin and causing 
irritation aud inflammation characterized by papules, vesi- 
cles and pustules. It attacks especially the ankles and legs. 
It is met with in the summer and autumn in the corn-fields, 
upon low bushes, in the grass and weeds along the banks- 
of rivers, and in swampy places. It is said to be very 
common along the Mississippi river. The little red mite 
encountered in the swamps and on the low ground of 



* American Naturalist, vol. vii. p. 16. 

f This is very closely allied to the species met with in various parts of 
Europe, and known as leptus (or acarus) autumnalis (also termed harvest-bug 
and mower's mite). 



584 PARASITES. 

New Jersey and Delaware is, in all probability, the same 
species. 

Either species are best treated with mild parasiticides, as, 
for example, a weak sulphur ointment, after the manner of 
scabies. 

Pulex Penetrans, or Sand Flea. — The sand flea (called 
also chigoe, chigger, and jigger) is a small, almost micro- 
scopic creature, similar in its general anatomy to the common 
flea. It possesses, however, a proboscis which is as long as 
its body. It perforates and burrows into the skin, and in 
the course of a few days produces a painful inflammation 
accompanied with swelling, large vesicles or pustules, and, at 
times, extensive ulceration. The impregnated female alone 
enters the skin and causes the mischief. It attacks the feet, 
and more particularly the toes, beneath and alongside of the 
nail, where the ova are deposited. 

The sand flea is met with in tropical countries only; it 
is common in the West Indies, and in Central and South 
America. It is said to exist also in Florida.* The treat- 
ment consists in extracting the intruder, which comes away 
in the form of a sac or bag as large as a small pea, being 
the abdomen enormously distended with ova. The various 
essential oils are used about the feet as a preventive against 
the attacks of the animal. 

Filaria Medinensis. — This parasite (known also as the 
Guinea-worm and dracunculns) is found only in tropical 
countries, and more particularly along the coast of Africa, 
and in Egypt, Persia, and India. It attacks the skin, giving 
rise to marked inflammation, which manifests itself in the 
form of a species of boil or painful tumor. The full-grown 
worm is about a half or three-quarters of a line in thickness, 
and varies from several inches to three feet in length accord- 
ing to its age. It has a roundish flattened form, tapers at 
either end, and is of a milk-white color. 

* In our southern states there is a little creature, termed by the natives 
also "jigger," which is not to be confounded with the sand flea; it is a red 
mite, and is in all probability the leptus irritans above described. 



(ESTRUS. 585 

The young worm, when of microscopic size, finds its way 
by boring into the skin and deeper tissues, and there takes 
up its habitat. It remains in the integument in, as it were, 
a latent state for a long period, usually months, during which 
time it grows to the size above indicated. Sooner or later 
local inflammation is set up in the form of a pointed tumor, 
accompanied by more or less swelling and pain, which 
breaks, showing the presence of the worm. One worm only 
is present in each tumor, although a number of them may 
infest different regions of the body at the same time. The 
lower extremities, especially the feet, are the parts generally 
attacked. The disease is usually contracted in swampy 
places aud on low grounds. 

The treatment consists in extracting the worm inch by 
inch, from day to day, as soon as it makes its appearance at 
the surface of the skin, care being taken not to break the 
creature in the operation. 

(Estrus, or Bot Fly. — This parasite not infrequently at- 
tacks man in Central and South America. It is also met 
with elsewhere. The ova are deposited by the fly in the 
skin, and there form inflammatory tumors or swellings, with 
a central point or aperture which discharges a sanious fluid. 
In the course of time the presence of the worm, grub, or 
bot, is discovered, which may be squeezed out or extracted. 

The various exposed portions of the surface are liable to 
be attacked, particularly the neck, back, and extremities. 
The fly very often deposits the ova unknown to the indi- 
vidual. There are several species of (Estrus which infest the 
human skin, of which (E. bovis is the most common. There 
is probably no species (E. hominis. 

Demodex Folliculorum.— This minute animal (also des- 
ignated steatozoon, entozoon, aud acarus, folliculorum) in- 
habits the sebaceous follicles of healthy, normal skin, and 
consequently gives rise to no symptoms whatsoever of dis- 
ease. It is microscopic, varying in length from -^" to \" ^ 
and has an elongated, rounded, worm-like form, made up of 
a head, thorax, and a long abdomen. Other, shorter, forms 



586 



PARASITES. 



are also found. From the thorax come off eight, short, stout, 
conical legs, all of the same size. The larva has only six 
legs. The abdomen is usually from two to three times the 
length of the thorax, and tapers off to a rounded point. 



m 



& 



'£■?*'!'■ 



Fig. XIII. — Demodex Folliculorum. (300 Diameters.) 
Ventral surface. (After Simon.) 

The parasite exists in the sebaceous glands of the skin, in 
both sexes, especially about the face, nose, ears, back, and 
chest, and lives on sebaceous matter. It is said not to occur 
in infants. It is entirely inoffensive, and is met with in 
healthy skin quite as often as in those cases where the seba- 
ceous glandular system is markedly disturbed, as, for exam- 
ple, in acne or in comedo. All persons, however, do not 
seem to possess the creatures; they are more apt to be 
present in thick, greasy skins than in thin, dry skins. They 
occur as often, at least, as two or three times in ten persons. 
Two, three or more of them often exist in one follicle. They 
are found imbedded in the sebaceous matter, lying length- 
wise with the follicle, with the head directed inwards. 

No difficulty is experienced in obtaining them from a 



PHTHEIRIASIS. 587 

likely subject. A prominent or patulous follicle or a comedo 
upon the nose or forehead may be squeezed out, and the 
contents placed on a glass slide with a drop of olive oil and 
covered with a thin glass, when with a power of from one 
to three hundred diameters, one or more of them will be 
usually found. The parasite was discovered by Henle, in 
1841, and also, at about the same time, by Gustav Simon, 
of Berlin.* 

PHTHEIRIASIS. 

Syn. Phthiriasis : Morbus Peclicularis ; Pedicularia ; Pediculosis; Malis 
Pediculi; Lousiness; Germ., L'ausesucht ; _F/\, Maladie Pediculaire. 

PHTHEIRIASIS is a contagious, animal parasitic affection, 

CHARACTERIZED BY THE PRESENCE OF PEDICULI AND THE LESIONS 
WHICH THEY PRODUCE, TOGETHER WITH SCRATCH MARKS, EXCORIA- 
TIONS, AND ITCHING. 

Symptoms. — Three varieties of the disease are encountered, 
which are designated according to the names of the species 
of pediculi which have their habitat upon the human body. 
The parasites are named pediculus capitis, pecliculus cor- 
poris, and pediculus pubis, frequenting, respectively, the 
head, body, and pubis. Their ravages are often very ex- 
tensive, always occasioning more or less discomfort, and at 
times great distress. The symptoms which they give rise 
to are somewhat different, and hence call for separate con- 
sideration. 

Phtheiriasis Capitis. — This is due to the presence of the 
pediculus capitis, or head louse. (See Fig. XIV.) It is found 
upon the scalp, and, as a rule, only upon this region of the 
body; occasionally, however, in elderly, bedridden subjects, 
it is met with on the general surface. It has an elongate 
ovalish shape, consisting of head, thorax, and abdomen, 
the latter of which is marked on either side with seven 
clearly defined, deep, angular notches, and a blackish linear 
margin. Six legs, similar in size and general features, 
strongly jointed, and armed with stout claws and hairs, come 
off from the thorax. The head is of a rounded acorn shape, 



* See Simon, loc. cit., p. 312. 



588 



PARASITES. 



and is furnished with two five-jointed antennae, and a pair of 
large, black, prominent eyes. The animal has an ashy-white 
or grayish color. It varies in length from \ ,n (1.4110 mm.) 
to \\' n (3.1749 mm.). The female is larger than the male. 
Upon the back of the male is seen a conspicuous and dis- 
proportionately large, conical or wedge-shaped structure, the 
penis. The ova, commonly termed " nits," are remarkably 
large (about a quarter of a line), pyriform or ovalish, whitish 
bodies, which are glued securely to the hairs. One, two, or 
more may be deposited on one hair. According to Kiichen- 
meister,* the young are hatched forth in six days. 




Fig. XIV. 



-Pediculus Capitis. (20 Diameters.) 
Female. Dorsal surface. 



The parasites may be present in small or in very great 
numbers, according to the length of time the affection has 
existed as well as other circumstances. They are found upon 
all portions of the head, their favorite seat being the occipital 
region. They are met with either upon the scalp itself, or 
upon the hairs at a considerable distance from the scalp. 
The ova are found deposited along the shaft of the hair. 

Pediculi capitis are encountered for the most part in chil- 
dren ; they are, however, also met with in adults, especially 
women. They are of not infrequent occurrence among the 
children of the poorer classes, and in public schools. They 



* The Animal and Vegetable Parasites of the Human Body, vol. ii. Syd. 
Soc. Translation. London, 1857. 






PHTHEIRIASIS. 589 

attack the scalp and give rise to considerable irritation, itch- 
ing, and consequent scratching, which is indulged in to such 
an extent that the scalp soon becomes wounded, and oozes 
a serous or purulent fluid mixed with blood, which in time 
mats the hair and forms into crusts. The greater the num- 
ber of pediculi, and the longer they are permitted to exist, 
the more extensive will be the lesions. The state of the 
general health of the patient will also influence the course 
of the affection ; the parasites will, as a rule, cause much 
more mischief in those who are under bad hygienic influ- 
ences, improperly cared for, and ill nourished, than in the 
healthy. In those predisposed to eczema the scalp will, in 
most cases, show marked symptoms of true eczema itself. 
Pediculi are, without doubt, accountable for a large share of 
the artificial eczema of the head met with in children among 
the poorer classes. 

Together with the pediculi, which may always be seen 
upon investigation crawling upon the hair, are found the ova, 
or nits. Very large numbers of these may usually be seen 
throughout the hair, at a distance often resembling in ap- 
pearance the tine scales of dry seborrhcea, Numerous ova 
may generally be found even in cases where the pediculi 
themselves are few. 

Where phtheiriasis capitis has existed for some time, the 
head usually presents a disgusting appearance, as well as 
an offensive, nauseous smell. As the disease continues the 
itching becomes intolerable, and the patient is unable to 
refrain from constant scratching; sleep is interfered with; 
the mind is harassed, and the general health more or less 
disturbed. 

Phtheiriasis Corporis.— The parasite here is the pedicu- 
lus corporis, or body louse (termed also, more properly, the 
pediculus vestimenti, or clothes louse). (See Fig. XV.) As 
regards its anatomical structure, it is very similar to the 
pediculus capitis, although it is considerably larger; it varies 
in length from f " (1.1576 mm.) to 2'" (4.2332 mm.). The 
female is larger than the male. It has an elongate, oval- 
ish shape, with seven well-marked indentations on either 
side of the abdomen, which are less angular and more 



590 PARASITES. 

rounded than in the case of the pediculus capitis. The abdo- 
men of the female is broader than that of the male, is more 
deeply notched upon the sides, and possesses a triangular- 
shaped notch at the end. The penis in the male is a re- 
markably large, wedge-shaped structure, situated on the 
back, and arising from the posterior portion of the middle 
of the abdomen. From the thorax spring the legs, three on 
either side, which are long, jointed, and provided with heavy 
claws and numerous small hairs. The head protrudes, is of 
a rounded acorn shape, and is armed with two hairy, five- 




Fm, XV. — Pediculus Corporis. (20 Diameters.) 
Female. Dorsal surface. 

jointed antennae, and prominent eyes. The color of the 
louse, when devoid of blood, is dirty-white or grayish, with 
a dark line around the margin of the abdomen. 

Its habitat is the clothes covering the general surface of the 
body and limbs; for it lives in the garments, only remaining 
upon the skin long enough to obtain its sustenance. Its ova 
are deposited and hatched in the clothing, usually beneath 
the seams. Where the pediculi are present in large numbers, 
some few may usually be observed upon the skin, either 
crawling about or in the act of drawing blood ; the vast ma- 
jority, however, will be found upon the clothes next to the 
surface, especially about the folds and seams of the under- 
garments. As they move about over the surface or attack 



PHTHEIRIASIS. 591 

the skill for food, they give rise to intensely disagreeable, 
itching sensations. The patient scratches, but obtains no 
permanent relief; as the parasites multiply, the itching be- 
comes so violent that the distress is almost unendurable. 
The scratching on the part of the patient is always severe, 
and is productive of scratch lines and marks, excoriations, 
bloodcrusts, pigmentation, thickening of the skin, and pus- 
tules with inflammatory bases and more or less crusting. 

The lesions are characteristic. The}' are peculiar in being 
multiform; the scratch marks are here and there long and 
streaked, in other places short and jagged; the excoria- 
tions and bloodcrusts are of all sizes, from a pin-head to 
a split pea and larger, and the pustules irregular in outline 
and without definite shape. They vary in severity with the 
duration of the affection and the general condition of the 
patient. Upon close inspection, in addition to the scratch 
marks and other secondary symptoms are seen the primary 
lesions, consisting of minute reddish puncta, or spots, with 
slight areolae, denoting the points at which the parasite has 
attacked the skin and drawn blood. 

The chief seats of the lesions are the back, especially about 
the scapular region, the chest, abdomen, hips and thighs; 
other portions of the general surface are also more or less 
involved. Where the affection has existed for months or 
years, as at times happens, a brownish pigmentation of the 
whole skin takes place, the result of long-continued irrita- 
tion and scratching. 

Phtheiriasis corporis is encountered for the most part in 
the middle-aged and elderly, although none are exempt from 
its invasion. Children, however, owing to the care which 
they usually receive, are seldom attacked. The complaint is 
a very frequent one among the poorer classes of all countries. 

Phtheiriasis Pubis.— The pediculus pubis, or crab louse 
(known also as phthirius inguinalis, phthirius pubis, and 
morpio), although having its seat of predilection about the 
pubis, may also infest the axillae, sternal region in the male, 
beard, eyebrows, and even eyelashes. (See Fig. XVI.) It is 
smaller than either the head louse or the body louse, meas- 
uring from \"> (1.0583 mm.) to V" (2.1166 mm.). It has a 



592 PARASITES. 

short, broad, flat, roundish or 3hield-shaped form, with a 
large, "fiddle-shaped" head, with two, stout, five-jointed 
antennae, and a pair of small, rather inconspicuous eyes. 
The thorax is short and passes imperceptibly into the abdo- 
men ; from the sides of the thorax come off six, jointed, 
hairy legs provided with powerful claws; the first pair are 
light, the second and third pair thick and heavy. The 
margin of the abdomen is slightly indented, and armed with 
eight, stout, conical or teat-shaped, prehensile feet, each 
with from four to ten bristles. The creature has a yellow- 
ish-gray color, and is more or less transparent. The female 
is larger than the male, and has a triangular-shaped notch 
at the termination of the abdomen. 




Fig. XVI.— Pedtctjlus Pubis. (20 Diameters.) 
Female. Dorsal surface. 

They may be found either crawling about the hairs or 
adhering closely to the surface of the skin. By means of 
the legs and bristles they cling with remarkable tenacity to 
the parts with which they may be in contact. The ova are 
small, whitish or yellowish bodies, and are found glued to 
the hairs, as in the case of those of the pediculus capitis. 
Here and there upon the skin, especially about the roots of 
the hairs, minute reddish particles may be seen, — the excre- 
ment of the parasite. 

Pediculi pubis infest adults chiefly, and occasion symp- 
toms similar to those described in connection with the other 
species. They are usually contracted through sexual inter- 
course ; at the same time, it must be stated, cases occasion- 
ally present themselves in which they have not been got in 



PHTHEIRIASTS. 593 

this way, and where no explanation as to the mode of conta- 
gion can be suggested. The amount of irritation to the skin 
which they produce varies; at times it is quite severe, in 
other cases it is comparatively insignificant. 

Etiology. — The cause of phtheiriasis is always to be found 
in the presence of the parasites. All individuals, the rich as 
well as the poor, the robust as well as the weakly, are equally 
liable to be attacked. As in scabies, contagion, direct or in- 
direct, is the only possible source from which the disorder 
may be contracted; now and then, through inaccurate ob- 
servation, it becomes a matter of no little difficulty to account 
for the mode of contagion.* 

In this connection the primary lesion produced by the 
pediculus, as well as the secondary lesions, may be briefly 
referred to. Considerable attention has been devoted to the 
minute anatomy of the head of the pediculus corporis by 
Landoisf and SchiodteJ. The latter of these investigators, 
whose studies are the more recent, has arrived at the con- 
clusion that pediculi are provided with a sucking apparatus, 
or haustellum, as originally suggested by Swammerdam, and 
not with a mouth and mandibles, as has been commonly 
supposed. Such being the anatomy, it is obvious that the 
pediculus does not bite, but, inserting the haustellum into 
a follicle, obtains blood by a process of sucking, producing 
a lesion which must be regarded in the light of a minute 
hemorrhage. This view is entertained also by Fox§ and 
others, and is without doubt correct. 

The secondary lesions are usually conspicuous, and are the 
effects of scratching upon skin which has been subjected to 
the ravages of the parasite. The longer the affection has 
existed, and the more numerous the pediculi are, the more 



* Views such as have from time to time been suggested, pointing to the 
" spontaneous generation" of pediculi, as well as to their having originated 
within the skin, it need scarcely be remarked, are without foundation and 
devoid of reason. 

f Zeit^chrift fur Wissenschaftliche Zoologie, Bd. xiv. and xv. 

+ Naturhistorisk Tidsskrift, ser. 3, vol. iii., Copenhagen, 1864-65; for 
translation, see Annals and Magazine of Natural History, ser. iii., vol. xvii.. 
1866. 

? Loc. cit., p. 413. 

38 



591 PARASITES. 

marked will these lesions be. The attacks of the pediculus, 
especially in the case of pediculi capitis and corporis, bring 
about a peculiarly irritable state of the skin which renders 
the desire for scratching one not to be resisted. As a conse- 
quence, scratching is indulged in, at first to a slight extent, 
but later to an inordinate degree, so that in the course of a 
few weeks the surface is, as a rule, well excoriated and lacer- 
ated from the effects of the finger-nails. In certain subjects, 
in addition to the excoriations, ecthymatous pustules are 
produced, which run the course of similar lesions due to 
other causes. The amount of pigmentation varies with the 
duration of the affection, and with other circumstances. 

Diagnosis. — The pediculi may always he found if sufficient 
care be taken to discover them. Frequently they are in 
small numbers, when considerable research and close ob 
servation may be required for their detection. After they 
have existed for some time, characteristic symptoms upon the 
skin manifest themselves; they may now readily be found if 
they are but suspected. When violent itching exists in a 
case without marked eruption, the possibility of their pres- 
ence should always be at least entertained and an investi- 
gation made. 

Phtheiriasis Capitis. — They are less liable to escape notice 
here than upon other regions of the body. The ova, or nits, 
which may be recognized even at a distance, serve as a val- 
uable diagnostic mark. The occipital region of the head 
especially is always more or less invaded, and by separating 
the hairs here they may generally be seen without further 
search. Scratch marks, serous or bloody oozing, matting of 
the hair, and crusts are also usually present. The affection 
is veiw apt to be mistaken for vesicular or pustular eczema. 
In this connection it is not to be forgotten that eczema is 
not infrequently complicated with phtheiriasis, and is to be 
explained in one of two ways; either the parasites have 
brought about the eczema, or, on the other hand, they have 
been contracted after the eczema, the diseased scalp consti- 
tuting a favorable abode for them; the former course, how- 
ever, is the more usual. In either case it is very important 
to arrive at a conclusion as to the primary trouble. 



- 



PHTHEIRIASIS. 

Phtheiriasis Corporis. — Pediculi of the body very often 
escape detection for the reason that their presence is not 
suspected. As already stated, their habitat is in the cloth- 
ing, and it is therefore to the undergarments that attention 
should be directed in looking for them. The seams and 
folds, especially of the undershirts and drawers, are to be 
examined, for it is here that the ova will be found. The 
extensive excoriations and bloodcrusts upon the shoulders 
and back, and the marks of the finger-nails upon various 
regions, will also aid in the diagnosis: they are, indeed, in 
severe cases characteristic. The minute, reddish, hemor- 
rhagic spots, indicating the points where the parasites have 
drawn blood, may also be recognized. 

Phtheiriasis of the body has long been seriously confounded 
with two very different diseases, namely, prurigo and pruritus. 
(See these disease?, diagnosis of, pp. 254 and 517.) Suffice it 
to say that an error in diagnosis cannot take place if the symp- 
toms of the diseases in question be borne in mind. It may 
at times be encountered in connection with other diseases, as, 
for example, scabies; in such cases, however, it is to be re- 
garded simply as a complication. The symptoms of scabies are 
so different from those of phtheiriasis as to call for no remark. 

Phtheiriasis Pubis. — Itching about the genitalia in either 
sex should always lead to a careful examination of the parts. 
The diagnosis will in all probabilitv be one of three dis- 
eases, namely, eczema, pruritus, or phtheiriasis pubis. The 
pediculi of this region, on account of their transparency 
and flatness, are at times difficult of recognition; they are, 
moreover, apt to adhere closely to the roots of the hairs 
and to the skin, when they present an appearance not unlike 
freckles or dirt specks. The excrement of the parasite will 
be found here and there about the roots of the hair and 
on the skin, in the form of minute reddish particles. The 
ova are readily seen as small, whitish or yellowish bodies, 
glued to the hairs. It will also be remembered that pediculi 
pubis not infrequently infest the axillae. Existing in either 
region they usually give rise to more or less irritation and 
annoyance^ especially at night; at times, however, they canse 
remarkably little cutaneous disturbance and discomfort. 



596 PARASITES. 

Treatment. — This is simple, the main object being the 
destruction of the parasites and their ova, The secondary 
lesions seldom demand attention ; as a rule, they disappear 
without special treatment. The various remedies used com- 
prise the mercurial preparations, staphisagria (seeds of Del- 
phinium staphisagria), pyrethrum (flowers of Pyrethrum car- 
neum and P. roseum), sulphur, sabadilla, cocculus Indicus, 
tobacco, carbolic acid, and petroleum. They are employed 
in the form of ointment, powder or lotion, as may be deemed 
most desirable and convenient. It need scarcely be added 
that strict regard to cleanliness, both of the person and with 
reference to the clothing and the toilet, should be enjoined. 

Phtheiriasis Capitis. — One of several plans may be em- 
ployed. The head may be well saturated with petroleum, 
enough being used to bathe the scalp, after which a bandage 
should be applied and the dressing kept on for twelve hours, 
as, through the night. In the morning the head should be 
thoroughly washed with hot water and soft soap. Where the 
parasites have not been completely destroyed the petroleum 
should be again applied in the same manner. One or two 
applications suffice. Care should be observed to prevent the 
petroleum from trickling down the neck, as it is liable to 
produce upon tender skin erythema or even blebs and ex- 
coriations. 

Powdered sabadilla or staphisagria may be sprinkled 
throughout the hair with good result. Decoction, infusion 
or tincture of cocculus Indicus is also a well known and re- 
liable remedy. Where there is not much excoriation of the 
skin, a lotion of corrosive sublimate, two grains to the ounce 
of water, or with alcohol and one of the essential oils, may 
be used; it is a cleanly and at the same time an efficacious 
mode of treatment. 

Ointments are not so advantageously employed as lotions, 
on account of their liability to mat the hair ; nevertheless, 
where the excoriations are extensive, or where eczema is 
present, they may very often be applied with decided benefit. 
White precipitate, ten or fifteen grains to the ounce of 
simple ointment, in these cases will be found valuable. 

The nits are to be removed by repeated washings with 



PIITHEIRIASIS. 597 

alkaline or acid lotions. Soda or borax washes, soft soap, 
vinegar, dilute acetic acid, and alcohol, will all prove of ser- 
vice in getting rid of these troublesome little bodies. It 
is seldom, if ever, necessary to cut oft* the hair. In young 
children, in cases where the ova exist in enormous numbers, 
there is perhaps no reason why the hair should not be cut, for 
the cure is without doubt thereby hastened ; but in women 
with long hair the sacrifice is great and the operation un- 
warrantable. With patience and time there is no difficulty 
whatever in relieving the hair of both pediculi and nits. 

Phtheiriasis Corporis. — In pediculi of the body the first 
and all-important step to be undertaken is to provide for the 
clothes, which always contain both the parasites and their 
ova. It is, indeed, the clothes (including all the wearing 
apparel of the individual), rather than the skin, that require 
treatment. Unless these can be changed and cared for, no 
satisfactory result need be looked for. They are to be either 
boiled or baked at a temperature sufficiently high to destroy 
life. In cases where it is impossible for the patient to have 
the clothes baked or boiled immediately, an ointment of pow- 
dered Btaphisagria, one or two drachms to the ounce, applied 
freely to the skin, has the effect of causing the parasites to 
disappear temporarily, and affords very decided relief for the 
time. 

Frequent baths of hot water and soap, and of bicarbonate 
of sodium, four ounces to the bath, are also important in re- 
lieving the excoriations, as well as the disagreeable itching, 
which is apt to continue even after the parasites have been de- 
stroyed. Lotions of carbolic acid, from one to two drachms 
to the pint of water with an ounce of glycerine, will also be 
found useful in allaying the irritability of the skin which is 
often encountered in cases of long standing. But, to repeat, 
it is to the clothes that the whole attention should be de- 
voted. The undergarments should in all cases be changed 
quite frequently for the first few days, and immediately 
boiled. They should be carefully examined from time to 
time, and if a single pediculus be found they should be sub- 
mitted again to treatment; unless these precautions receive 
minute attention the parasites are very apt to reappear. The 



598 PARASITES. 

lack of proper scrutiny upon this point will account for the 
cases of chronic phtheiriasis of the body, who wander about 
for years laboring under the impression that they never can be 
permanently relieved. Instances of this kind are, even at 
the present day, still met with. Patients should invariably 
be informed as to the nature of their trouble, and assured 
further that by heed to the treatment and instructions given 
a short time will suffice for entire relief. 

Phtheiriasis Pubis. — This requires very simple measures 
for its cure. Any of the ointments or lotions alread} T spoken 
of may be applied morning and evening, care being observed 
to have them well rubbed into the skin. The tincture of 
cocculus Indicus, full strength or diluted, and corrosive sub- 
limate lotion, already referred to, will be found both clean 
and effectual remedies. Infusion of tobacco will also answer 
the purpose. The parts should be well washed twice daily 
with soft soap and water, and the remedy applied for several 
days after the pediculi have been destroyed, to insure com- 
plete destruction of the ova, which otherwise are apt to hatch 
out. White precipitate ointment and mercurial ointment, 
both considerably weakened, are well known and effectual 
remedies which may be mentioned. 

Prognosis. — After the remarks which have been made, little 
need be said concerning the termination of the disease. It 
is always satisfactory, provided the patient is able to follow 
the necessary instructions. It is here that the trouble at 
times arises in relieving certain cases; circumstances will 
not permit of the treatment. The affection may continue 
.indefinitely unless properly treated. 

Cimex Lectularius, Acanthia Lectularia, or Common 
Bedbug. — This insect is not infrequently the cause of mis- 
chief upon the skin. It is found in beds, about the joints, 
grooves and crevices, and in the bedding and bedclothes, 
about the seams and folds ; also in the cracks of old floors and 
walls, wall-paper, and furniture, and in other like places. It 
lives upon human blood. It is very tenacious of life, and is 
said to be able to live without food for a very long period. 
It possesses a strong and offensive " cinnamon-like" odor, 



PULEX IRKITAXS. 599 

which is particularly noticeable when the insect is crushed. 
The bedbug exists quite universally; according to Kiichen- 
meister it is not found in South America, Australia, nor in 
the Polynesian islands. 

The cutaneous lesion which it produces is of the nature of 
an urticarial wheal, consisting of a circumscribed, slightly 
raised, split-pea sized, erythematous spot with a whitish 
centre, and at times attended with considerable swelling. 
The lesion is a hemorrhage, which remains as a reddish 
point after the wheal has subsided. The sensation accom- 
panying the act of drawing blood is that of a very slight 
prick, followed in a few minutes by decided itching and 
burning almost identical with that of urticaria. Scratching 
usually takes place, followed at times by extensive excoria- 
tions and bloodcrusts. 

Among the lower classes in over-crowded, old frame 
houses, these pests very often exist in great numbers and 
at times occasion much suffering, especially in children. 
The bedbug is said to have a foe in the cockroach; also, 
according to Prof. Riley,* in the "two-spotted corsair" (Pi- 
rates biguttatus) met with in beds infested with bedbugs in 
southern Illinois, and in Louisiana, Texas, California, and 
Mexico. 

According to the same authority, the "blood-sucking 
cone-nose," or "big bedbug" (Conorhinus sanguisuga), has 
been found in beds in southern Illinois and Ohio; it prob- 
ably does not occur further north. This species is said to 
produce lesions followed by quite severe inflammation of 
the skin. 

The bites of the bedbug are relieved by lotions containing 
alcohol, cologne water, carbolic acid, vinegar, dilute acetic 
acid, corrosive sublimate, lead water, water of ammonia, and 
similar remedies, sponged upon the parts. The best pre- 
ventives against bugs in beds and other haunts are corrosive 
eublinuite and pyrethrum powder. 

PULEX IBRITANS, Or COMMON FLEA.-This little pest is 



* American Entomologist, vol. I p. 85. 



600 PARASITES. 

found quite universally. It is, however, more common in 
warm than in cold climates. Although it provokes no seri- 
ous cutaneous disturbance, it is nevertheless, in certain parts 
of the world, especially in tropical countries, the source of 
much discomfort to man. 

The lesion which it produces is an erythematous spot 
with a minute, central, dark, hemorrhagic point. Flea-bites 
may be mistaken for purpura simplex; the areola with which 
the central point of the bite is surrounded will, however, 
suffice to establish the diagnosis. 

Culex, or Mosquito. — This insect (of which there are 
many species, e.g. 0. pipiens), common to almost every sec- 
tion of our country, is not infrequently the source of con- 
siderable irritation upon the skin, causing an urticarial lesion, 
or wheal, varying in its general features with the sensitive- 
ness of the skin. (See foot-note, p. 821.) The itchiness of 
the bites is best relieved with a lotion of ammonia water. 

The " midge" and " black fly' 7 of the northern states and 
Canada (both species of Simulium) also give rise to much 
annoyance during the early summer months, occasioning 
lesions similar to those of the mosquito. 

Ixodes, or Tick. — There are several species of tick which 
are met with in our woods, and which are liable to attach 
themselves to the human skin. They insert their proboscis 
and head deeply into the tissues, and suck blood until they 
not infrequently swell up to many times their natural size. 
They should never be extracted with violence, but should 
be induced to relinquish their firm hold upon the skin by 
dropping upon them some oily substance, as olive oil or one 
of the essential oils. 



BIBLIOGRAPHY 



Anderson, M'Call. — A Practical Treatise upon Eczema, including its 

Lichenoids and Impetiginous Forms. Third edition, with illustration?. 

Philadelphia, 187-3. 
Anderson. M'Call. — On the Parasitic Affections of the Skin. Second 

edition. London, 1868. 
Andeksox. M'Call. — On Psoriasis and Lepra. London, 1865. 
A.KDEBSON, M'Call. — On the Treatment of Diseases of the Skin, with an 

Analysis of Eleven Thousand Consecutive Cases. London. 1872. 
Bazin. — Affections Cutanees de Nature Arthritique et Dartreuse. Deuxieme 

edition. Paris, 1868. 
Bazin. — Affections Generiques de la Peau. Paris, vol. i., 1862, vol. ii., 1805. 
Bazin. — Affections Cutanees Parasitaires. Deuxieme edition. Paris, 1862. 
Baztx. — La Scrofule. Deuxieme edition. Paris, 1861. 
Bumstead. — The Pathology and Treatment of Venereal Diseases. Third 

edition. Philadelphia, 1870. 
Devergie. — Traite Pratique des Maladies de la Peau. Deuxieme edition. 

Ouvrage accompagne de planches coloriees. Paris, 1857. 
Fotjrnier. — Lecons sur la Syphilis etudiee plus particulierement chez la 

Femme. Paris, 1873. 
Fox, Tilbury. — Skin Diseases: their Description, Pathology, Diagnosis, and 

Treatment. Second American from third English edition. New York, 

1873. 
Hardy. — Lecons sur les Maladies Dartreuses. Troisieme edition. Paris, 1868, 
Hardy. — Lecons sur les Maladies de la Peau. Deuxieme edition. Paris, 1863. 
Hardy.— Lecons sur la Scrofule et les Scrofulides et sur la Syphilis et les 

Syphilides. Paris, 1861. 
Hebra.— Handbuch der Speciellen Pathologic und Therapie. Dritter Band. 

Acute Exanthemc und Hautkrankheiten. Erlangen, 1860. 
Hebra (and Kohn).— Handbuch der Speciellen Patbologie und Therapie. 

Dritter Band, zweiter Theil, erste Lieferung. Erlangen, 1870. 
Hebra , and Kaposi).— Handbuch der Speciellen Patbologie und Therapie. 

Dritter Band, zweiter Theil. zweite Lieferung. Erlangen, 1872. 
Hebra (and Kaposi).— Handbuch der Speciellen Patholegie und Therapie. 

Dritter Band, I. Abtheilung, zweite Auflage. Erlangen, 1871. 
Hebra | and Kaposi).— On Diseases of the Skin, including the Exanthemata. 

New Svdenham Society's Translation, vols, i.-iv. London. 1806-1875. 

601 



602 BIBLIOGRAPHY. 

Kaposi. — Syphilis der Haut and der angrenzenden Sehleimhaiite, mit Tafeln 
in Chromolithographie ausgefuhrt von Dr. Carl Heitzmann. In drei 
Lieferungvn. Wien. 1873, 1874, 1875. 

KiYiienmeister. — On Animal and Vegetable Parasites of the Human Body. 
Sydenham Society's Translation, vol. ii. London, 1857. 

Milton, J. L. — The Pathology and Treatment of Diseases of the Skin. Lon- 
don, 1872. 

Neligan. — A Practical Treatise on Diseases of the Skin. Dublin, 1852. 

Neumann, I. — Lehrbuch der Hautkrankheiten. Dritte Auflage. Wien, 
1873. 

Neumann, I. — Hand-book of Skin Diseases. Translated from the Second 
German edition, with Notes, by Lucius D. Bulkley, A.M., M.D., New- 
York, 1872. 

Hayek. — A Theoretical and Practical Treatise on the Diseases of the Skin. 
Second edition, with an Atlas. (Translated from the French, by K. 
Willis, M.D.) London, 1835. 

Simon, Gltstay. — Die Hautkrankheiten durch Anatomische Untersuchungen 
erliiutet. Zweite Auflage. Berlin, 1851. 

Thomson, A. T. — A Practical Treatise on Diseases affecting the Skin. 
London, 1850. 

Wilson, Erasmus. — On Diseases of the Skin, a System of Cutaneous Medi- 
cine. Sixth edition. London, 1867. 

Van Bur en and Keyes. — A Practical Treatise on the Surgical Diseases 
of the Genito-Urinary Organs, including Syphilis. New York, 1874. 



INDEX. 



Aeanthia lectularia, 598. 
Acarus autumnalis (note), 583. 

fulliculorum, 585. 

scabiei, 575. 
A cli or ion Sehonleinii, 530. 
Achroma, acquired, 381. 

congenital, 380. 
Acne, 257. 

artificialis, 260. 

atrophica, 259. 

cachectic. 261. 

diagnosis of, 262. 

disseminata. 257. 

etiology of, 260. 

hypertrophica, 259. 

indurata, 259. 

papulosa, 259. 

pathology of, 262. 

prognosis of, 268. 

punctata, 259. 

pustulosa, 259. 

symptoms of, 257. 

treatment of, constitutional, 263, 
local, 266. 
Acne albida, 119. 

boutonneusc, 257. 

bromine. 260. 

iodine, 260. 

mentagra, 277. 

vulgaris, 257. 
Acne rosacea, 269. 

diagnosis of, 273. 
etiology of, 271. 
pathology of, 273. 
prognosis of, 277. 
symptoms of, 269. 
treatment of, 275. 
Acne sebacea, 102. 

sebacee. 102. 

syphilitica, 463. 

tar, 260. 

varioliformis, 121. 
Acneform syphiloderm, 463. 
Acquired achroma, 381. 

leucasmus, 381. 



Acquired leucopathia, 381. 

piebald skin, 381. 

Acuminated pustular svphiloderm, 

* small, 4b2. 

large, 463. 

Addison's disease, bronzing of skin in, 

339. 
Adipose tissue, 23. 
Age, in diagnosis, 74. 

influence of, in etiologv, 56. 
Albinism, 380. 
Albinismus, 380. 
Albinos, 380. 
Aleppo boil, 317. 
bouton, 317. 
evil, 317. 
Algidite progressive, 365. 
Algor pro^ressivus, 365. 
Alopecia, 391. 

congenital, 391. 
idiopathic premature. 392. 
senile, 391. 
simplex, 392. 

symptomatic premature, 392. 
syphilitic, 393. 
treatment of, 394. 
Alopecia areata, 395. 

diagnosis of, 398. 
etiology of, 396. 
pathology of, 397. 
prognosis of, 401. 
treatment of, 399. 
Alopecia circumscripta, 395. 
Alphos, 291. 

American harA^est mite, 583. 
Anaemia, 65. 
Anaesthesia, 525. 

dolorosa, 526. 
Anesthetic leprosy, 435. 
Analgesia, 526. 

Anatomy of the bloodvessels, 24. 
corium, 21. 
epidermis, 19. 
hair follicle, 35. 
hairs, 33. 
lymphatics, 24. 
muscles, 29. 

603 



604 



INDEX. 



Anatomy of the nails, 38. 
nerves, 25. 
Pacinian corpuscles, 

27. 
pigment, 29. 
sebaceous glands. 31 . 
skin, 17. 

subcutaneous connect- 
ive tissue, 23. 
sweat glands, 30. 
tactile corpuscles, 20. 
Angioma lipomatodes, 499. 
Anidrosis, 131. 

treatment of, 132. 
Anodynia, 525. 

Anomaliae secretionis, 98, 102. 
Anthrax, 318. 

diagnosis of, 320. 
etiology of, 319. 
pathology of, 319. 
prognosis of, 321. 
symptoms of, 318. 
treatment of, 320. 
Aperients, in treatment, 88. 
Aplasie lamineuse progressive, 385. 
Appendages of the skin, 18. 
Area Celsi, 395. 
Army itch, 575. 
Arsenic, in treatment, 85. 
Artificial acne, 260. 
eruptions, 327. 
Asiatic pills, 303. 
Atheroma, 124. 
Atrophia cutis. 385. 
linearis, 386. 
propria, 385. 
Atrophia?, 100. 

Atrophic lines and spots, 386. 
Atrophies, 100, 379. 
Atrophy, 69. 

of the face, unilateral, 385. 
hair, 401. 
hair pigment, 384. 
nail. 403. 
skin, 385. 
senile. 390. 
Aussatz, der, 432. 



B. 



Baldness, idiopathic premature, 392. 

of old age, 391. 
Barbadoes leg, 367. 
Barber's itch, 553. 
Bartfinne, 277. 
Bath, continuous (note), 245. 
Baths, in treatment, 89. 
Bedbug, common, 598. 
Bibliography, 601. 
Biskra bouton, 317. 



Black fly, 600. 
Blanching of the hair, 384. 
Blasenausschlag, 237. 
Blascben, 43. 
Blasen, 44. 
Blebs, 44. 

Blood-sucking cone-nose, 599. 
Bloodvessels, 24. 
Bloody sweat, 335. 
Blutfleckenkrankheit, 330. 
Blutschwar, 314. 
: Body louse, 589. 
Boil, 314. 

Aleppo, 317. 

Delhi, 317. 
Borken, 47. 
Bot fly, 585. 

Boucnemia tropica, 367. 
Bouton, Aleppo, 317. 

Biskra, 317. 
Brandsehwar, 318. 
Broad condyloma, 453. 
Bromidrosis, 129. 

symptoms of, 129. 

treatment of, 130. 
Bromine acne, 260. 
Bulla?, 44. 
Bulles. 44. 
Bullous syphiloderm, 468. 



C. 



Cachectic acne, 261. 

Calculi, cutaneous, 119. 

Callositas, 343. 

Callosity, 343. 

Callus, 343. 

Calvities, senile., 391. 

Cancer, epithelial, 486. 

Cancroid, 486. 

Cancroide, 404. 

Caneroide, 486. 

Canities, 384. 

Carbolic acid, in treatment, 87. 

Carbuncle, 318. 

Carcinoma cutis, 486. 
epitheliale, 486. 

Cauliflower excrescence, SCO. 

Cause of the disease, in treatment, 82. 

Causes of disease, external, 60. 
internal, 57. 
i Caustics, in treatment, 93. 

Chaps, 165. 
: Charbon, 322. 

Cheloide, 404. 

Chigger, 584. 

Chigoe, 584. 

Chloasma, 338. 

diagnosis of, 340. 



INDEX. 



605 



Chloasma, pathology of, 340. 

symptoms of, 338. 

treatment of, 340. 

uterinum, 339. 
Chloasma (Wilson), 561. 
Chromidrosis, 130. 

pathology of, 130. 

symptoms of. 130. 

treatment of, 131. 
Cicatrices, 50. 
Cimex lectularius, 598. 
Cingulum, 220. 
Claret stain, 498. 
Classification, 98. 
Clavus, 345. 

etiology of, 345. 

pathology of, 346. 

treatment of, 346. 
Climate, influence of, in etiology. 56. 
Clothes louse, 589. 

Clothing, influence of, in etiology. GO. 
Cod-liver oil, in treatment, 84. 
Color of disease, in diagnosis, 77. 
Comedo, 116. 

diagnosis of, 117. 

etiology of, 116. 

pathology of, 117. 

prognosis of, 119. 

symptoms of, 116. 

treatment of, 118. 
Common bedbuir, 598. 

flea, 599. 

wart, 349. 
Conditions influencing disease, 50. 
Condylom, spitze (note), 350. 
Condyloma, broad or flat, 453. 

pointed (note), 350. 

subcutaneum, 121. 
Congenital achroma, 380. 

alopecia, 391. 

leucasmus, 380. 

leucoderma, 380. 

leucopathia, 380. 

syphilis, 469. 
Connective tissue, subcutaneous, 23. 
Conorhinus sanguisuga, 599. 
Constitutional diseases, influence of, 
in etiology, 57. 

disturbance, in diagnosis, 74. 

treatment, 83. 
Contagion, influence of, in etiology, 61. 
Contagious impetigo, 285. 

molluscum, 121. 
Continuous bath (note), 245. 
Cor, 345. 
Corium, 21. 

papillary laj^er, 22 

pars papillaris, 22. 

pars reticularis, 22. 

reticular layer, 22. 
Corn, 345.. 



Corn, hard, 345. 

soft, 345. 
Come de la peau, 347. 
Cornu cutaneum, 347. 

etiology of, 348. 
pathology of, 348. 
symptoms of, 347. 
treatment of, 349. 
Cornu humanum, 347. 
Corpuscles of Meissner, 26. 

of Vater, 27. 

of Wagner, 26. 

Pacinian, 27. 

tactile, 26. 
Corsair, two-spotted, 599. 
Couperose, 269. 
Crab louse, 591. 
Croutes, 47. 
Crusta lactea, 161. 
Crustaa, 47. 

Crusted ringworm, 528. 
Crusts, 47. 
Culex, 600. 

pipiens, 600. 
Cuniculus, 570. 
Cutaneous calculi, 119. 

horn, 347. 

tumors, 47. 
Cuticle, 19. 
: Cutis, 21. 

anserina, 29. 

pendula, 371. 

tensa chronica, 361. 

unctuosa, 102. 



D. 



Dandriff, 102 

Dandruff, 102. 

Dartre rongeanto, 421. 

Decrepitude infantile, 305. 

Defluvium capillorum, 393. 

Delhi boil, 317. 

Demodex folliculorum, 585. 

Dentition, influence of, in etiologv, 

59. 
Derma, 21. 
Dermalgia, 510. 
Dermalgie, 510. 
Dcrmatalgia, 510. 

diagnosis of, 512. 

etiology of, 511. 

pathology of, 512, 

prognosis of, 513. 

symptoms of, 510. 

treatment of, 512. 
Dermatite cxfoliatricu generalisce 

(note), 313. 
Dermatitis, 323. 

calorica, 328. 



G06 



INDEX. 



Dermatitis traumatica, 324. 

venenata, 325. 
Dermatitis circumscripta herpetifor- 
mis (note), 219. 

contusiformis, 144. 

exfoliativa, 311. 
Dermatolysis, 371. 

diagnosis of, 373. 

etiology of, 373. 

pathology of, 373. 

symptoms of, 371. 

treatment of, 373. 
Dermatosclerosis, 361. 
Dermatosyphilis, 446. 
Diachylon ointment, 188, 193. 
Diagnosis, 72. 

age in, 74. 

constitutional disturbance in, 74. 

distribution of the disease in, 77. 

examination in, 73. 

general features of the disease in, 
77. 

habits in, 75. 

inspection in, 73. 

light in, 72. 

occupation in, 76. 

sex in, 75. 

temperature of the apartment in, 
72. 
Discoloration, 41. 

Disorders of internal organs, influ- 
ence of, in etiology, 58. 
Disorders of secretion, 102. 
Dissection wounds, 322. 
Distribution of disease, in diagnosis, 

77. 
Diuretics, in treatment, 88. 
Dracunculus, 584. 
Dusting powders, in treatment, 90. 
Dvsidrosis, 236. 



E. 



Ecehymomata, 329. 
Ecchymoses, 329. 
Ecthyma, 288. 

diagnosis of, 290. 

etiology of, 289. 

pathology of, 289. 

prognosis of, 291. 

treatment of, 290. 
Ecthyma syphiliticum, 464. 
Ecthymaform syphiloderm, 464. 
Eczema, 156. 

aeute, 165. 

ani, 209. 

articulorum, 208. 

artificial, 169. 

aurium, 207. 

barbae, 205. 



Eczema capitis, 198. 
chronic, 165. 
constitutional causes of, 167. 

treat mm 
crurum, 211. 
diagnosis of, 174. 
diagnosis from artificial inflam- 
mations, 181. 

erysipelas, 176. 

erythema simplex, 177. 

herpes, 177. 

lichen planus, 178. 

pemphigus, 177. 

pityriasis rubra, 179. 

psoriasis, 1 78. 

scabies, 180. 

scarlatina, 176. 

seborrhoea, 177. 

sycosis, 179. 

syphilis, 181. 

tinea circinata, 179. 

tinea favosa, 180. 

urticaria, 177. 
erythematosum, 158. 
etiology of, 166. 
faciei ^203. 
fendille, 165. 
fissum, 165. 
genitalium, 208. 
impetiginosum, 161. 
intertrigo, 170, 209. 
labiorum, 203 
local causes of, 169. 

treatment of, 184. 
acute, 185. 
chronic, 189. 

varieties of, their diagnosis 
and treatment, 197. 
madidans, 163. 
ma mm arum, 210. 
manuum, 213. 
mercuriale, 169. 
palmarum et plantarum, 214. 
palpebrarum, 204. 
papulosum, 162. 
pathology of, 171. 
prognosis of, 196. 
pustulosum, 161. 
riniosum, 165. 
rubrum, 163. 
sclerosum, 165. 
solare, 170. 
squamosum, 164. 
symptoms of, 156. 
treatment of, 181. 
umbilici, 211. 
unguium, 215. 
universale, 197. 
verrucosum, 165. 
vesiculosum, 159. 
Eczema marginatum (note), 538. 



INDEX. 



GOT 



Eczemaform syphiloderm, 464. 
Electricity, in treatment, 94. 
Elephant "leg, 367. 
Elephantiasis Arabum, 367. 

diagnosis of, 370. 
etiology of, 369. 
pathology of, 369. 
prognosis of, 371. 
symptoms of, 367. 
treatment of, 370. 
Elephantiasis Grsecorum, 432. 

anaesthetica, 435. 
diagnosis of, 440. 
etiology of, 436. 
pathology of, 438. 
prognosis of, 443. 
symptoms of, 432. 
treatment of, 441. 
tuberculosa, 434. 
Encysted tumor, 124. 
Endemic verrugas, 433. 
Entozoon follieulorum, 585. 
Ephidrosis, 125. 

cruenta, 335. 
Epidermis, 19. 

horny layer of, 19. 
mucous layer of, 20. 
stratum corneum of, 19. 
stratum mucosum of, 20. 
Epithelial cancer, 486. 
Epithelialkrebs, 486. 
Epithelioma, 486. 

deep-seated, or infiltrating variety 

of, 487. 
diagnosis of, 493. 
etiology of, 490. 
papillary variety, 489. 
pathology of, 491. 
prognosis of, 496. 
superficial, or flat variety of, 486. 
symptoms of, 486. 
treatment of, 494. 
Equinia, 323. 
Erbgrind, 528. 
Erectores pili, 29. 
Erythema, 41. 
Erythema centrifuge, 415. 
Erythema intertrigo, 137. 

etiology of, 138. 
symptoms of, 137. 
treatment of, 138. 
Erythema multiforme, 141. 
annulare, 141. 
diagnosis of, 143. 
etiology of, 142. 
iris, 141. 

marginatum, 141. 
papulatum, 141. 
pathology of, 143. 
prognosis of, 144. 



Erythema multiforme, symptoms of, 
141. 
treatment of, 143. 
tuberculatum, 14 1. 
Erythema nodosum, 144. 

diagnosis of, 145. 
etiology of, 14:1. 
pathology of, 145. 
prognosis of, 14U. 
symptoms of. 1-14. 
treatment of, 146. 
Erythema simplex, 135. 

diagnosis of, 136. 
from Caloric, 135. 
poisons, 136. 
traumatism, 135. 
idiopathic, 135. 
symptomatic, 136. 
symptoms of, 135. 
treatment of, 137. 
Erythematous eczema, 158. 
syphilide, 448. 
syphiloderm, 448. 
Erytheme noueux, 144. 
Esthiomene, 421. 
Etiology, 55. 
age in , 56. 
climate in, 56. 
clothing in, 60. 

conditions influencing disease, 56. 
constitute nal diseases in, 57. 
contagion in, 61. 
dentition in, 59. 

disorders of internal organs in, ^"8. 
external causes in, 60. 
food in, 58. 
hereditability in, 57. 
internal causes in, 57. 
irritants in, 61. 
medicine in, 59. 
occupation in, 60. 
predisposition in, 57. 
pregnancy in, 59. 
scratching in, 61. 
seasons in, 56. 
sex in, 56. 
uncleanliness in, 61. 
vaccination in, 59. 
Evil, Aleppo, 317. 
Examination of patient, in diagnosis, 

73. 
Excessive sweating, 125. 
Excoriationes, 48. 
Excoriations, 48. 

Excrescence, cauliflower (note), 350. 
Exsudationes, 99, 140. 
Extent of disease, in diagnosis, 77. 
External causes of disease, 60. 
Exudation, 66. 
Exudations, 99, 140. 



608 



INDEX. 



Farcy, 323. 
Favus, 528. 
Febris urticata, 146. 
Feuergiirtel, 220. 
Fever'blister, 21G. 
Fibroma molluscum, 407. 
Fibrous molluscum, 407. 
Fig wart (note), 3-50. 
Filaria medinensis, 584. 
Finn en, 257. 

Fisehschuppenausscblag, 353. 
Fish-skin disease, 353. 
Fissures, 49. 

Flat pustular syphiloderm, small, 464. 
large, 464. 

condyloma, 453. 
Flea, common, 599. 
Fleckc, 40. 
Fleckenmal, 342. 
Fluxus sebaceus, 102. 
Fly, black, 600. 

bot, 585. 
Follicular elevations, 119. 

tumor, 124. 
Food, influence of, in etiology, 58. 

in treatment, 84. 
Fragilitas criniuin, 402. 
Fragility of the hair, 402. 
Framboesia, 443. 
Freckle, 336. 
Fressende flechte, 421. 
Furoncle, 314. 
Furuncle, 314 
Furunculosis, 314. 
Furunculus, 314. 

diagnosis of, 316. 

etiology of, 315. 

pathology of, 315. 

prognosis of, 317. 

symptoms of, 314. 

treatment of, 316. 



G. 

Gale, 570. 

General considerations, 17. 

features of the disease, in diagno- 
sis, 77. 
Geschwiire, 50. 
Glanders, 323. 
Glands, sebaceous, 31. 

sweat, 30. 
Gneis, 102. 
Goose-flesh, 29. 

Graying of the hair, sudden, 384. 
Grayness of the hair, 384. 
Greisenhaftigkeit der kinder, 365. 
Grutum, 119. 
Guinea worm, 584. 
Gumma, 467. 



Gummatous syphilide, 40"; 

syphiloderm, 467. 
Gummy tumor, 467. 
Gurtelkrankheit, 220. 
Gutta rosacea, 269. 

rosea, 269. 



II . 



Habits, in diagnosis, 75. 
Hrematidrosis, 335. 
Haemidrosis, 335. 

, Hemorrhagic, 100. 
Hair, sudden graving of, 384. 

follicle, 35. 
Hairs, 33. 

Harvest mite, American, 58-^. 
irritating, 583. 
bug (note), 583." 
Hautabschiirfungen, 48. 
Hauthorn, 347. 
Hautpapillom (note), 353. 
Hautschrunden, 49. 
Hautsclerem, 361. 
Head louse, 587. 
Heat, prickly, 230. 
Hemorrhage, 68. 
idiopathic, 329. 
symptomatic, 330. 
Hemorrhages, 100, 329. 
Hemorrhoea petechialis, 330. 
Hereditability, influence of, in eti- 
ology, 57. 
Hereditary syphilis, infantile, 469. 
Herpes circinatus, 227, 537. 

bullosus(note), 218. 
circine, 537. 
esthiomenos, 421. 
Herpes febrilis, 216. 

facialis. 216. 
labialis, 217. 
progenitalis, 217. 
preputialis, 217. 
symptoms of, 216. 
treatment of, 218. 
Herpes gestationis, 218. 

impetiginiformis, 219. 
Herpes iris, 227. 

diagnosis of, 229. 
etiolosw of, 228. 
pathology of, 229. 
prognosis of, 230. 
symptoms of, 227. 
treatment of, 230. 
Herpes zoster, 220. 

diagnosis of, 224. 
etiology of, 222. 
pathology of, 223. 
prognosis of, 227. 
treatment of, 225. 



ItfDEX. 



609 



Honeycomb ringworm, 528. 
Horn, cutaneous, 347. 
Horny excrescence, 347. 

layer of epidermis, 19. 

tumor, 347. 
Huhnerauge, 345. 
Hvclroa, 227. 

febrilis, 216. 

vesiculeux, 227. 
Hydradenitis, 317. 
Hygiene, in treatment, 83. 
Hyperemia, 64. 
Hypersemiae, 99, 134. 
Hyperemias, 99, 134. 
Hyperesthesia, 509. 
Hyperidrosis, 125. 

diagnosis of, 127. 

etiology of, 127. 

pathology of, 127. 

prognosis of, 129. 

symptoms of, 125. 

treatment of, 127. 
Hypertrichosis, 373. 
Hypertrophic, 100. 
Hypertrophic papules, 454. 
Hypertrophies, 100, 336. 
Hypertrophy of the hair, 373. 

etiology of, 375. 
treatment of, 375. 
Hypertrophy of the nail, 376. 

treatment of, 378. 

of the skin, 371. 



Ichthyose, 353. 
Ichthyosis, 353. 

diagnosis of, 358. 

etiology of, 356. 

hystrix, 354. 

nigricans, 356. 

pathology of, 357. 

prognosis of, 359. 

simplex, 354. 

symptoms of, 353. 

treatment of, 358. 
Ichthyosis congenita, 353. 

sebacea, 102. 

vera, 353. 
Idiopathic diseases, 55. 
Idrosis, 125. 
Ignis sacer, 220. 
Impetigo, 281. 

diagnosis of, 284. 

etiology of, 283. 

pathology of, 283. 

symptoms of, 281. 

treatment of, 285. 
Impetigo contagiosa, 285. 

diagnosis of, 287. 



Impetigo contagiosa, etiology of, 286. 

pathology of, 286. 

prognosis of, 288. 

symptoms of, 285. 

treatment of, 288. 
Impetigo syphilitica, 464. 
Impetigoform syphiloderm, 464. 
Individual lesions of disease, in diag- 
nosis, 77. 
Induratio tele cellulosae neonatorum, 

365. 
Inflammation, 66. 
product of, 66. 
Inspection of patient, in diagnosis, 73. 
Internal causes of disease, 57. 
Intertrigo, 137, 170, 209. 
Iodide of potassium, in treatment, 88. 
Iodine acne, 260. 
Iron, in treatment, 84. 
Irritants, influence of, in etiology, 61. 
Irritating harvest mite, 583. 
Itch, 570. 

army, 575. 
mite, 570. 
Ixodes, 600. 



J. 



Jigger, 584. 
Juckblattern, 



250. 



K. 

Kelis, 404. 
Keloid, 404. 

cicatricial, 40G. 

diagnosis of, 406. 

etiology of, 405. 

pathology of, 406. 

prognosis of, 407. 

spontaneous, 405. 

symptoms of, 404. 

treatment of, 407. 
Keloid of Addison, 38 
Keratoses, 348. 
i Kerion, 552. 
Kleienflechte, 561. 
Knollen, 47. 
j Knollenkrebs, der 

Knotchen, 41. 
I Knoten, 46. 
i Kratze, 570. 
Krusten, 47. 
Kupferrose, 269 
Iv up frige ™< 



404. 



cesicht, das, 209. 



Land scurvy, 332. 
Lanugo, 33. 



39 



610 



INDEX. 



Lausesucht, 587. 

Leichdorn, 345. 

Lenticular papular syphiloderm, 452. 

Lentigo, 336. 

etiology of, 337. 
pathology of, 338. 
symptoms of, 336. 
treatment of, 338. 
Leontiasis, 432, 435. 
Lepra, 291, 432. 
alphos, 291. 
Arabum, 432. 
Lepre, la, 432. 
Leprosy, 432. 

anaesthetic, 435. 
tubercular, 433. 
Leptus, 583. 

Americanus, 583. 
autumnalis (note), 583. 
irritans, 583. 
Lesions of the skin, 40. 
color of, 54. 
configuration of, 52. 
distribution of, 52. 
locality of, 53. 
primary, 40. 
secondary, 47. 
symmetry of, 53. 
Leucasmus, acquired, 381. 

congenital, 380. 
Leucoderma, acquired, 381. 

congenital, 380. 
Leucopathia, acquired, 381. 

congenital, 380. 
Lice, 587. 

Lichen hypertrophique (note), 353. 
Lichen pilaris, 359. 

diagnosis of, 360. 
symptoms of, 859. 
treatment of, 361. 
Lichen planus, 246. 

diagnosis of, 249. 
etiology of, 248. 
pathology of, 248. 
prognosis of, 250. 
symptoms of, 246. 
treatment of, 249. 
Lichen ruber, 246. 
Lichen scrofulosus, 256. 

diagnosis of, 257. 
etiology of, 256. 
pathology of, 256. 
symptoms of, 256. 
treatment of, 257. 
Lichen simplex, 162. 
syphiliticus, 451. 
tropicus, 230. 
urticatus, 148. 
Light, in diagnosis, 72. 
Lineae albicantes, 387. 
Linear atrophy, 386. 



Local treatment, 89. 
Lotions, in treatment, 91. 
Louse, body, 589. 
clothes, 589. 
crab, 591. 
head, 587. 
Lousiness, 587. 
Lupus erythematodes, 415. 
Lupus erythematosus, 415. 
diagnosis of, 417. 
etiology of, 416. 
pathology of, 417. 
prognosis of, 420. 
symptoms of, 415. 
treatment of, 418. 
Lupus exedens, 421. 
sebaceus, 415. 
superficialis, 415. 
vorax. 421. 
Lupus vulgaris, 421. 

diagnosis of, 423. 
etiology of, 422. 
exedens, 421. 
exfoliativus, 421. 
exulcerans, 421. 
hypertrophicus, 421. 
pathology of, 423. 
prognosis of, 429. 
treatment of, 425. 
tuberculosus,421. 
Lymphadenie cutanee, 503. 
Lymphadenoma cutis, 503. 

pathology of, 504. 
symptoms of, 503. 
Lymphadenoma of the skin, 503. 
Lymphangioma cutis, 502. 
Lymphatics of the skin, 24. 



M. 



Maculae, 40. 

Maculae et s'triae atrophica?, 386. 

Macular syphilide, 448. 

syphiloderm, 448. 
Macules, 40. 

Maladie pediculaire, 587. 
Malignant pustule, 322. 
Malis pediculi, 587. 
Medicine, influence of, in etiology 

59. 
Melanoderma, 338. 
Melasma, 338. 
Melitagra, 160. 
Mentagra, 277. 
Mercury, in treatment, 87. 
Method of treatment, 83. 
Microsporon furfur, 563. 
Midge, 600. 
Miliaria, 230. 



INDEX. 



• ill 



Miliaria alba, 231. 
diagnosis of, 233. 
etiology of, 232. 
papulosa, 230. 
pathology of, 233. 
prognosis of, 236. 
rubra, 231. 
symptoms of, 230. 
treatment of, 235. 
vesiculosa, 231. 
Miliaria crystallina, 132. 
Miliary fever (note), 230 

papular syphiloderm, 451. 
pustular syphiloderm, 462. 
Milium, 119. 

diagnosis of, 120. 
etiology of, 120. 
pathology of, 120. 
symptoms of, 119. 
treatment of, 120. 
Mineral spring waters, in treatment, 

88. 
Moist papule, 453. 

wart (note), 350. 
Mole, pigmentary, 342. 
Molluscum contagiosum, 121. 
Molluscum fibrosum, 407. 

diagnosis of, 409. 
etiology of, 408. 
pathology of, 409. 
prognosis of, 410. 
symptoms of, 407. 
treatment of, 410. 
Molluscum non-contagiosum, 407. 

pendulum, 407. 
Molluscum sebaceum, 121. 

diagnosis of, 122. 
etiology of, 121. 
pathology of, 122. 
prognosis of, 124. 
symptoms of, 121. 
treatment of, 123. 
Molluscum sessile, 121. 

simplex, 407. 
Morbus maculosus "WerlhofBi, 332. 

pedicularis, 587. 
Morphoea, 387. 

diagnosis of, 389. 
etiology of, 388. 
pathology of, 389. 
prognosis of, 390. 
symptoms of, 387. 
treatment of, 390. 
Morphcea of leprosy (note\ 387. 
Morpio, 591. 
Mosquito, 600. 
Mower's mite (note), 583. 
Mucous layer of epidermic, 20. 
papule, 453. 
patch, 453. 
Muscles of the skin, 29. 



X. 



Nsevus flammeus, 498. 

pigmentaire, 342. 
Naevus pigmentosus, 342. 

pilosus, 342. 

sanguineus, 498. 

s F ilus, 342. 

vascularis, 498. 
Naevus vasculosus, 498. 

pathology of, 498. 
treatment of, 499. 
Naevus verrucosus, 342. 
Nails, 38. 
Narben, 50. 
Nature of the disease, in treatment, 

82. 
Neoplasmata, 101. 
Nervenschmerz der haut, 510. 
Nerves of the skin, 25. 

medullated, 26. 

non-medullated, 28. 
Nesselausschlag, 146. 
Nettle rash, 146. 
Neuralgia of the skin, 510. 
Neuroma cutis, 505. 

multiplex (note), 505. 

of the skin, painful, 505. 
Neuroses, 101, 509. 
New growths, 70, 101, 404. 
Noli me tangere, 421. 
Non-parasitic sycosis, 277. 
Norwegian scabies (note), 574. 



0. 



Objective symptoms, 40. 
Occupation, influence of, in etiology, 
60. 

in diagnosis, 76. 
Odor hircinus, 130. 
OEstrus, 585. 
Oils, in treatment, 91. 
Oily seborrhcea, 104. 
Ointment, diachylon, 188, 193. 

rumex (note), 276. 
Ointments, in treatment, 92. 
Onychauxis, 377. 
Onychia, 377. 

" syphilitic, 378. 
Onycho-gryphosis, 377. 
Onycho-mycosis, 378. 
Osmidrosis, 129. 



Pachydermatocele, 371. 
PachVdermia, 367. 
Pacinian corpuscles, 27. 



612 



INDEX. 



Painful neuroma of the skin, 505. 

tubercle, subcutaneous, 508. 
Panniculus adiposus, 23. 
Papilla), 22. 

Papillary layer of corium, 22. 
Papilloma area-elevatum (note), 353. 
Papilloma cutis, 353. 
Papulae, 41. 
Papular acne, 259. 

eczema, 162. 

miliaria, 230. 

syphilide, 451. 

syphiloderm, 451. 
large, 452. 
miliary, 451. 
small, 451. 

urticaria, 148. 
Papule, moist, 453. 

mucous, 453. 
Papules, 41. 

hypertrophic, 454. 

vegetating, 454. 
Papulosquamous syphiloderm, 454. 
Parasitse, 101. 
Parasitare bartfinne, 553. 
Parasites, 70, 101, 527. 
Parasitic mentagra, 553. 

sycosis, 553. 
Parasiticides, in treatment, 94. 
Paronychia, 377. 
Pars papillaris, 22. 

reticularis, 22. 
Patch, mucous, 453. 
Pathology, 63. 

anaemia, 65. 

atrophy, 69. 

hemorrhage, 68. 

hyperemia, 64. 

hypertrophy, 69. 

inflammation, 66. 

new growths, 70. 

parasites, 70. 
Pedicularia, 587. 
Pediculosis, 587. 
Pediculus capitis, 587. 

corporis, 589. 

pubis, 591. 

vestimenti, 589. 
Peliosis rheumatica. 331. 
Pellagra, 445. 
Pemphigus, 237. 

acutus, 239. 

cachecticus, 239. 

chronicus, 239. 

diagnosis of, 242. 

etiology of, 240. 

feigned (note), 243. 

foliaceus, 239. 

gangrasnosus, 239. 

malignus, 239. 

pathology of, 241. 



Pemphigus, prognosis of, 246. 

pruriginosus, 239. 

symptoms of, 237. 

treatment of, 243. 

vulgaris, 238. 
Pemphigus prurigineux (note), 218. 

syphiliticus, 468. 
Pendulous growth, 371. 
Perspiration, sensible, 18. 

insensible, 18. 
Pessema (note), 353. 
Petechias, 329. 

Phosphorus, in treatment. 87. 
Phtheiriasis, 587. 

capitis, 587, 594, 596. 

corporis, 589, 595, 597. 

diagnosis of, 594. 

etiology of, 593. 

prognosis of, 598. 

pubis, 591, 595, 598. 

symptoms of, 587. 

treatment of, 596. 
Phtbiriasis, 587. 
Phthirius inguinalis, 591. 

pubis, 591. 
Phymata, 47. 
Pian, 443. 

Piebald skin, acquired, 381. 
Pigment of the skin, 29. 
Pigmentary mole, 342. 
Pigmentmal, 342. 
Pirates biguttatus, 599. 
Pityriasis, 102. 

pilaris, 359. 
Pityriasis rubra, 311. 

diagnosis of, 313. 
etiology of, 312. 
pathology of, 312. 
symptoms of, 31 1. 
treatment of, 313. 
Pityriasis versicolor, 561. • 
Plantar syphiloderm, 455. 
Plaque muqueuse. 453. 
Plica, 374. 

Polonica, 374. 
Pointed condyloma (note,) 350. 

wart (note), 350. 
Poison dogwood, dermatitis from, 325. 

ivy, dermatitis from, 325. 

sumach, dermatitis from, 325. 

vine, dermatitis from, 325. 
eczema from, 169. 
Poisoned wounds, 321. 
Polytrichia, 373. 
Pomphi, 45. 
Pompholyx, 237. 
Porcupine disease, 355. 
Pore, 30. 
Porrigo decalvans, 395. 

favosa, 528. 

furfurans, 544. 



INDEX. 



613 



Port wine stain. 408. 
Poultices, in treatment, 90. 
Predisposition, influence of, in eti- 
ology, 57. 
Pregnancy, influence of, in etiology, 

59. 
Present general condition, in treat- 
ment, 81. 
Previous history, in treatment, 81. 
Prickle cells, 20. 
Prickly heat, 230. 
Primary lesions. 40. 
Production cornee, 317. 
Prognosis, 96. 
Prurigo, 250. 

diagnosis of, 253. 

etiology of, 232. 

pathology of, 252. 

prognosis of, 255. 

symptoms of, 250. 

treatment of, 255. 
Pruritus, 513. 

diagnosis of, 516. 

etiology of, 515. 

pathology of, 516. 

prognosis of, 521. 

symptoms of, 513. 

treatment of, 517. 
Pruritus hiemalis, 521. 
Psora, 291. 
Psoriasis, 291. 

circinata, 294. 

diagnosis of, 297. 

from eczema, 298. 

lupus erythematosus, 300. 
seborrheca, 300. 
syphilis, 298. 
tinea circinata, 300. 

diffusa, 294. 

etiology of, 295. 

guttata, 293. 

gyrate, 294. 

nummularis. 204. 

pathology of, 200. 

prognosis of, 310. 

punctata, 293. 

symptoms of, 291. 

treatment of, 300. 
Psoriasis of the mouth and tongue 
(note), 295. 

syphilitica, 454. 
Pterygium of the nail, 377. 
Pulex irritans, 599. 

penetrans, 584. 
Purpura, 330. 

hemorrhagica. 332. 

pathology of, 333. 

prognosis of, 335. 

rheumatica, 331. 

simplex, 330. 

symptoms of, 330. 



Purpura, treatment of, 334. 
Purpura urticans, 149. 

urticata, 149. 
P u stein, 45. 
Pustula maligna, 322. 
Pustulae, 45. 
Pustular acne, 259. 
eczema, 161. 

eczemaform syphiloderm, 464. 
syphilide, 461. 
syphiloderm, 461. 

large acuminated, 463. 
large flat, 464. 
miliary, 462. 
small acuminated, 462. 
small flat, 464. 
Pustules, 45. 
Pustulo-crustaceous lesions, 461. 



Quaddeln, 45. 

Quinine, in treatment, 85. 



R. 



Rete Malpighii, 20. 

mucosum, 20. 
Reticular layer of corium, 22. 
Rhagades, 49. 

Rheumatism of the skin, 510. 
Rhinosclerom, 412. 
Rhinoscleroma, 412. 

diagnosis of, 414. 

etiology of, 413. 

pathology of, 413. 

prognosis of, 414. 

symptoms of, 412. 

treatment of, 414. 
Rhinophyma, 271. 

Rhus toxicodendron, dermatitis from, 
325. 

venenata, dermatitis from, 325. 
Rib cells, 20. 
Ringworm, 528. 

Burmese (note), 538. 

Chinese (note), 538. 

crusted, 528. 

honeycomb, 528. 

of the body, 537. 

of the scalp, 544. 
Rodent ulcer, 487. 
Rosacea, 501. 
Roseola, 136. 

syphilitica, 448. 
Rumex ointment (note), 276. 
Rupia, 465, 468. 



614 



INDEX. 



Sand flea, 584. 
Sapo viridis, 192. 
Sarcoma cutis, 497. 
Sarcoptes hominis, 575. 

scabiei, 575. 
Satyriasis, 432. 
Scabies, 570. 

diagnosis of, 578. 

etiology of, 574. 

Norwegian (note), 574. 

pathology of, 575. 

prognosis of, 583. 

symptoms of, 570. 

treatment of, 580. 
Scales, 48. 
Scars, 50. 

Scherende flechte, 544. 
Schmeerfluss, 102. 
Schuppen, 48. 
Sehuppenflechte, 291. 
Sclerem der neugeborenen, 365. 
Sclerema, 361. 
Sclerema neonatorum, 365. 

diagnosis of, 366. 
etiology of, 366. 
pathology of, 366. 
symptoms of, 365. 
treatment of, 366. 
Sclerema of the newborn, 365. 
Sclereme des adultes, 361. 
Scleriasis, 361. 
Scleroderma, 361. 

diagnosis of, 364. 

etiology of, 362. 

pathology of, 362. 

prognosis of, 364. 

symptoms of, 361. 

treatment of, 364. 
Scleroderma neonatorum, 365. 
Sclerodermic, 361. 
Scleroma adultorum, 361. 
Sclerostenosis, 361. 
Scratching, influence of, in etiology, 

61. 
Scrofula, 429. 

Scrofulide boutonneuse benigne (Ba- 
zin), 250. 

erythemateuse, 415. 

tuberculeuse, 421. 
Scrofuloderma, 429. 

diagnosis of, 431. 

etiology of, 431. 

pathology of, 431. 

symptoms of, 429. 

treatment of, 432. 
Scrofulosis, 429. 
Scurvy, land, 332. 

Seasons, influence of, in etiology, 56. 
Sebaceous cyst, 124. 



Sebaceous cyst, diagnosis of, 125. 
pathology of, 125. 
symptoms of, 124. 
treatment of, 125. 
Sebaceous glands, 31. 

matter, 33. 

tumor, 124. 
Seborrhagia, 102. 
Seborrhcea, 102. 

capitis, 105. 

corporis, 107 

diagnosis of, 110. 

etiology of, 108. 

faciei, 105. 

genitalium, 107. 

nasi, 106. 

oleosa, 104. 

pathology of, 109. 

prognosis of, 115. 

sicca, 104. 

symptoms of, 102. 

treatment of, 111. 
Seborrhcea congestiva, 415. 
Sebum, 33. 

Secretion, disorders of, 102. 
Senile atrophy, 390. 

calvities, 391. 
! Sex, influence of, in etiology, 56. 

in diagnosis, 75. 
Shingles, 220. 
Simulium, 600. 
Skin, anatomy of, 17. 

appendages, 18. 

bloodvessels, 24. 

corium, 21. 

epidermis, 19. 

hair follicle, 35. 

hairs, 33. 

horny laj'er, 19. 

lanugo, 33. 

lymphatics, 24. 

medullated nerves, 26. 

mucous layer, 20. 

muscles, 29. 

nails, 38. 

nerves, 25. 

non-medullated nerves, 28. 

Pacinian corpuscles, 27. 

papillary layer, 22. 

pigment, 29. 

reticular layer, 22. 

sebaceous glands, 31. 

sebaceous matter, 33. 

subcutaneous connective tissue, 
23. 

sweat glands, 30. 

tactile corpuscles, 26. 
Smegma, 103. 
Soaps, in treatment, 89. 
Sommersprosse, 336. 
Spargosis, 367. 



INDEX. 



615 



Special diseases, 102. 

Spedalskhed, 432. 

Spitze condvlom (note), 350. 

Spots, 40. 

Squamae, 48. 

Sq names, 48. 

Squamous papule, 43. 

papules, 454. 

syphilide, 454. 

syphiloderm, 454. 
Stage of disease, in diagnosis, 77. 
Stain, claret, 498. 

port wine, 498. 
Stearrhoea, 102. 
Steatoma, 124. 
Steatorrhcea, 102. 
Steatozoon folliculorum, 585. 
Stone pock, 257. 
Stratum corneum of epidermis, 19. 

mucosum of epidermis, 20. 
Striae et maculse atrophicaa, 386. 

idiopathic, 386. 
symptomatic, 387. 
Strophulus albidus, 119. 
Strophulus prurigineux (Hardy), 250, 

252 (note). 
Struma, 429. 
Subcutaneous connective tissue, 23. 

painful tubercle, 508. 
Subjective symptoms, 54. 
Sudamina, 132. 

etiology of, 132. 

pathology of, 133. 

symptoms of, 132. 
Sudamina (Hebra), 230. 
Sudatoria, 125. 

Sudden graying of the hair, 38J. 
Sweat, bloody, 335. 

colored, 130. 
Sweat glands, 30. 
Sweating, excessive, 125. 
Sycosis, 277. 

contagiosa, 553. 

non-parasitaire, 277. 
Sycosis non-parasitica, 277. 
diagnosis of, 279. 
etiology of, 278. 
pathology of, 278 
prognosis of, 281. 
symptoms of, 277 
treatment of, 280. 
Sycosis parasitaire, 553. 

parasitaria, 553. 

parasitica, 553. 
Symptomatic diseases, 55. 
Symptomatology, 40. 

bullae, 44. 

color in, 54. 

configuration in, 52. 

crusts, 47. 

distribution in, 52. 



Symptomatology, excoriations, 48. 

fissures, 49. 

general symptoms in, 51. 

locality in, 53. 

maculae, 40. 

objective symptoms, 40. 

papulae, 41. 

primary lesions, 40. 

pustulae, 45. 

scales, 48. 

scars, 50. 

secondary lesions, 47. 

subjective symptoms, 54. 

symmetry in, 53. 

tubercula, 46. 

tumors, 47. 

ulcers, 50. 

vesiculae, 43. 

wheals, 45. 
Symptoms, general, 51. 

objective, 40. 

subjective, 54. 
Syphilide, acneform, 463. 

bullous, 468. 

ecthymaform, 464. 

erythematous, 448. 

gummatous, 467. 

herpetiform (note), 462. 

impetigoform, 464. 

large acuminated pustular, 463. 

large flat pustular, 464. 

large papular, 452. 

lenticular papular, 452. 

macular, 448. 

miliary papular, 451. 

miliary pustular, 462. 

palmar, 455. 

papular, 451. 

papulosquamous, 454. • 

pigmentary, 460. 

plantar, 455. 

pustular, 461. 

pustular eczemaform, 464. 

serpiginous tubercular, 466. 

small acuminated pustular, 462. 

small flat pustular, 464. 

small papular, 451. 

squamous, 454. 

tubercular, 465. 

varicellaform, 459. 

variolaform, 463. 

vesicular, 459. 
Syphilides, 446. 
Syphilis, congenital. 469. 

hereditary, 469. 

infantile, 469. 
of the skin, 446. 
Syphilis cutanea, 446. 

bullosa, 468. 
erythematosa, 448. 
ffuinmatosa, 467. 



616 



INDEX. 



Syphilis cutanea maculosa, 448. 

papillomatosa. 406. 

papulosa, 451. 

pustulosa, 461. 

squamosa, 454. 

tuberculosa, 465. 

vegetans, 454. 

vesiculosa, 459. 
Syphilitic acne, 463. 
alopecia, 393. 
coryza, 470. 
ecthyma, 464. 
impetigo, 464. 
lichen, 451. 
pemphigus, 468. 
psoriasis, 454. 
roseola, 448. 
Syphiloderm, acneform, 463. 
bullous, 458. 
ecthymaform, 464. 
erythematous, 448. 
gummatous, 467. 
herpetiform (note), 462. 
impetigoform, 404. 
large acuminated pustular, 463. 
large flat pustular, 464. 
large papular, 452. 
lenticular papular, 452. 
macular, 448. 
miliary papular, 451. 
miliary pustular, 462. 
palmar, 455. 
papular, 451. 
papulo-squamous, 454. 
pigmentary, 460. 
plantar, 455. 
pustular, 461. 
pustular eczemaform, 464. 
serpiginous tubercular, 466. 
small acuminated pustular, 462. 
small flat pustular, 464. 
small papular, 451. 
squamous, 454. 
tubercular, 465. 
varicellaform, 459. 
variolaform, 463. 
vesicular, 459. 
Syphiloderma, 446. 

absence of itching in, 448. 

bullosum, 468. 

color of, 448. 

concomitant symptoms in, 447. 

configuration of the lesions in, 

448. 
constitutional treatment of, 475. 
course of, 448. 
erythematosum, 448. 
general symptoms in, 446. 
gummatosum, 467. 
haereditarium infantile, 469. 
local treatment of, 485. 



Syphiloderma, multiformity of the 
lesions in, 447. 

papulosum, 451. 

pathology of, 473. 

pigmentosum, 460. 

pustulosum, 461. 

seat of, 447. 

treatment of, 475. 

tuberculosum, 465. 

vesiculosum, 459. 
Syphiloma, 467. 



T. 

Taches, 40. 

Tactile corpuscles, 26. 
Tar acne, 260. 
Tar, in treatment, 87. 
Teigne faveuse, 528. 
tondante, 544. 
tonsurante, 544. 
Telangiectasis, 500. 
Temperament, in diagnosis. 75. 
Temperature, in diagnosis. 72. 
Tetter, 156. 
Tick, 600. 
: Tinea amiantacea, 102. 

asbestina, 102. 
| Tinea circinata, 537. 

diagnosis of, 541 . 

etiology of, 539. 

pathology of, 539. 

prognosis of, 544. 

symptoms of, 537. 
treatment of, 543. 
Tinea decalvans, 395. 
Tinea favosa, 528. 

diagnosis of, 533. 

etiology of, 530. 

pathology of, 531. 

prognosis of, 536. 

symptoms of, 528. 

treatment of, 534. 
Tinea furfuracea, 102. 

kerion, 552. 
Tinea sycosis, 553. 

diagnosis of, 558. 

etiology of, 555. 

pathology of, 556. 

prognosis of, 561. 

symptoms of, 553. 

treatment of, 559. 
Tinea tondens, 544. 
Tinea tonsurans, 544. 

diagnosis of, 548. 

etiology of, 546. 



pathology of, 546. 
prognosis of, 552. 
symptoms of. 544. 
treatment of, 550. 



INDEX. 



617 



Tinea tricophytina, 536. 
unguium, 538. 
Tinea versicolor, 561. 

diagnosis of, 566. 
etiology" of, 563. 
pathology of, 564. 
prognosis of, 569. 
symptoms of, 561. 
treatment of, 568. 
Tissue, adipose, 23. 

subcutaneous connective, 23. 
Treatment, 80. 

cause of the disease in, 82. 
constitutional, 83. 
aperients in, 88. 
arsenic in, 85. 
cod-liver oil in, 84. 
diuretic- in, 88. 
food in, 84. 
hygiene in, 83. 
iodide of potassium in, 88. 
iron in, 84. 
mercury in, 87. 
mineral spring waters in, 88. 
phosphorus in, 87. 
quinine in, 85. 
tar, carbolic acid in, 87. 
local, 89. 

baths in, 89. 
caustics in, 93. 
dusting powders in, 90. 
electricity in, 94. 
lotions in, 91. 
oils in, 91. 
ointments in, 92. 
parasiticides in, 94. 
poultices in, 90. 
soaps in, 89. 
method of, 83. 
nature of the disease in, 82. 
present general condition in, 81. 
previous history in, 81. 
Trichauxis, 373. 
Trichiasis, 374. 
Trichonosis cana, 384. 
discolor, 384. 
furfuracea, 544. 
Trichorexis nodosa, 402. 
Tricophytie circinee, 537. 

sycosique. 553. 
Tricophyton, 536, 539, 540, 547, 557. 

tonsurans, 546. 
Tricoptilosis, 402. 
True skin, 21. 

Tubercle, subcutaneous painful, 508. 
Tubercles, 46. 
Tubercula, 46. 
miliaria, 119. 
sebacea, 119. 
Tubercular leprosy, 433. 
syphilide, 465. 



Tubercular syphiloderm, 465. 

serpiginous, 466. 
Tumeurs, 47. 

Tumeurs folliculeuses, 121. 
Tumor, encvsted, 124. 

follicular, 124. 

gummy, 467. 

sebaceous, 124. 
Tumores, 47. 

sebipari, 121. 
Tumors, 47. 

Two-spotted corsair, 599. 
Tvloma, 343. 
Tvlosis, 343. 



U. 



Ulcer, rodent, 487. 

Ulcers, 50. 

Uncleanliness, influence of, in etiologv, 

61. 
Urticse, 45. 
Urticaire, 146. 
Urticaria, 146. 

acute, 149. 

bullosa, 149. 

chronic, 149. 

diagnosis of, 152. 

etiology of, 150. 

hemorrhagica, 149. 

papulosa, 148. 

pathology of, 151. 

prognosis of, 155. 

symptoms of, 146. 

treatment of, 152. 



Yaccination. influence of, in etiology ; 

59. 
Varicellaform syphiloderm, 459. 
Variolaform syphiloderm, 463. 
Varus, 257. 
Vegetating papules, 454. 

syphiloderm, 454. 
Vegetation dermique (note), 350. 
Venereal wart (note), 350. 
Vernix caseosa, 103. 
Verruca, 349. 

acuminata, 350. 

digitata, 350. 

etiology of, 351. 

filiformis, 349. 

pathology of, 351. 

plana, 349. 

prognosis of, 352. 

symptoms of, 349. 

treatment of, 352. 

vulgaris, 349. 



618 



INDEX, 



Verruca elevata (note), 350. 
Verrugas, endemic, 443. 
Verue, 349. 
Vesicles, 43. 
Vesiculse, 43. 
Vesicular eczema, 159. 

miliaria, 231. 

syphilide, 459. 

svphiloderm, 459. 
Vibices, 329. 
Vitiligo, 381. 

diagnosis of, 382. 

etiology of, 382. 

pathology of, 382. 

prognosis of, 383. 

symptoms of, 381. 

treatment of, 383. 
Vitiligoidea, 410. 
Vleminckx's solution, 309. 



W. 

Wart, 349. 

fig (note), 350. 

moist (note), 350. 

pointed (note), 350. 1 

venereal (note), 350. 
Warze, 349. 
Wen, 124. 
Werlhoffii, morbus maculosus, 332. 



Wheals, 45. 
Whelk, 257. 

Whiteness of the hair, 384. 
Wounds, dissection, 322. 
poisoned, 321. 



X. 

Xanthelasma, 410. 
Xanthoma, 410. 

etiology of, 411. 

pathology of, 411. 

symptoms of, 410. 

treatment of, 412. 
Xeroderma, 353, 354. 

ichthyoides, 353. 



Yaws, 443. 



Zellgewebsverhartung der neugebo- 

renen, 365. 
Zona, 220. 
Zoster, 220. 



THE END. 



3477 
X300 



ERRATA. 

In the chapter upon the Anatomy of the Skin the measurement V" should 
have been valued at 2.116 mm. instead of 2.136 mm. 
On page 336, for Summersprosse read Sommersprosse. 
On page 385, for Eulenberg read Eulenburn:. 
On page 531, for 1826 read 1876. 



618 



INDEX. 



Verruca elevata (note), 350. 
Verrugas, endemic, 443. 
Verue, 349. 
Vesicles, 43. 
Vesiculse, 43. 
Vesicular eczema, 159. 

miliaria, 231. 

syphilide, 459. 

svphiloderm, 459. 
Vibices, 329. 
Vitiligo, 381. 

diagnosis of, 382. 

etiology of, 382. 

pathology of, 382. 

nrop-nosis of. 383. 



Wheals, 45. 
Whelk, 257. 

Whiteness of the hair, 384. 
Wounds, dissection, 322. 
poisoned, 321. 



X. 

Xanthelasma, 410. 
Xanthoma, 410. 

etiology of, 411. 

pathology of, 411. 

symptoms of, 410. 



347? 
X300 



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